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NEW  ELEMENTS
OF
OPERATIVE    SURGERY:
                        BY

           ALF, A. L, M. VELfEAU,

Professor of Surgical CUnique of the Faculty of Medicine of Paris, Surgeon of the Hospital of La
      Charite, Member of the Eoyal Academy of Medicine, of the Institute, etc.,

       CAREFULLY REVISED, ENTIRELY REMODELLED, AND AUGMENTED 'WITH

   A  TREATISE ON  MINOR  SURGERY.

                    ILLUSTEATED BY

       OVER 200 ENGRAVINGS, INCORPORATED WITH THE TEXT:
                   ACCOMPANIED WITH

  AN ATLAS IN QUARTO OF TWENTY-TWO PLATES,

     EEPRESENTING THE PRINCIPAL OPERATIVE PROCESSES, SUBGICAL INSTRUMENTS, ETC.

                TRANSLATED WITH ADDITIONS BY

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

       UNDER THE SUPERVISION OF, AND WITH NOTES AND OBSERVATIONS BY
            VALENTINE MOTT, M.D.
Professor of the Operations of Surgery with Surgical and Pathological Anatomy, in the University of
      New York; Foreign Associate of the Academie Royale de Medecine of Paris,
               of that of Berlin, Brussels, Athens, etc
               FOURTH EDITION, WITH ADDITIOgg^T^
        GEORGE C.  BLACKMAN, M.D.,
  Professor of Surgery in the Medical College of Ohio, Surgeon to the Commercial Hospital, etc
                                   - C-
               IN THREE VOLUMES.
                   VOL. III.
HMO
         NEW  YORK:
SAMUEL  S. &  W.  WOOD,
       No. 389 BROADWAY.
             1856.
^ 
wo
        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 Toik.
   STEREOTYPED BY                          PRINTED BY
 THOMAS B. SMITH,                   E N. GROSSMAN
82 & 84 Beekman Street, N. Y.                     84 Beekman St. 
PREFACE
TO  THE THIRD AND  LAST  VOLUME  OF  THIS  WORK.

             BY   P.   S.   TOWNSEND,  M.D.
  If it were possible that any portion of these volumes could be considered more
valuable to students and to practitioners than the rest, we should say, apart from the
great capital  operations on aneurisms,  amputations, exsections, &c,  in  the 2d
volume, and the rudimental subjects of minor surgery and  the new operations em-
braced in the 1st volume,—that the special operations on all the varied regions of
the human body, contained in this 3d and last volume, especially in relation to the
important subjects of Hernia and Tumors, and those most  difficult manipulations
exacted in the minute and delicate surgery of the face, neck, and all the different
vital organs and passages considered separately, together with the  accompanying
beautiful quarto atlas of nearly 200 figures  of surgical instruments and processes,
would unquestionably bear the palm of precedence for direct practical utility.
  The whole, as will be perceived, have  been treated of with the habitual felicitous
manner of M. Velpeau, both in regard to the perspicuity of the style of the author,
and his intimate practical  familiarity with the operations themselves.  But for
having been already somewhat accustomed, however, to his manner of describing
surgical processes, we should have  despaired of rendering some of the more intri-
cate of  these operations intelligible in our own language.
  We tfrust we have succeeded, at  least  we count  with some degree of security on
not having committed in any place, any sensible deviation from the path traced out
for  us, while endeavoring to adhere as closely as  possible  to  the meaning of the
original, and at the same time to  convey the ideas of the author into our own
idiom, in a manner, we hope, not entirely wanting either in spirit or perspicuity.
  We are gratified in being enabled to  state from a recent letter of M. Velpeau,
that the work, so far as it had progressed, had met with his entire approbation ; so
much so, that he  hesitates  to our  enquiry of  his intention to publish a second
French  edition, by saying that he should  meditate upon this present work, in order
to satisfy himself first, that the necessity of such a task had not been fully antici-
pated by our labors.
  The text of this present volume, we may furthermore remark, is so  ample and
searching in its details, and so perfectly au courant to the present condition of  sur-
gery, in respect to the subject-matters therein embraced, that any attempt almost
on our part, to superadd any thing new to what M. Velpeau himself has said, has
been almost entirely  superseded.   Nevertheless, it will be  perceived that we have
deemed it advisable to incorporate some  100 pages of new matter in various places,
among which the animated discussion still in progress, on the diagnosis of Fibrous
and Cancerous Tumors, and the important, though brief remarks of  Dr. Mott on
his  eminently successful  mode of treating the  distressing  affection of Immobility
of the Lower Jaw, will, we are sure, be found of some interest to the profession.
  While touching on this matter, we may remark, that in  a case of this kind, and
as an auxiliary to the  screw-lever of Dr. Mott,  the right masseter muscle  wa9
totally divided, and the left partially so, as early as  the year 1840, by James
R.  Wood,  M. D.  of this city.  Complete success, however,  did not reward the
bold expedient of this skilful  young surgeon, which,  however, might  possibly
have been obtained if it had occurred to him  to have adopted the ingenious re-
source of his preceptor,  Dr. Mott, by severing also the pterygoid muscles. 
IV
PREFACE.
   We are somewhat strengthened in this opinion by what happened in the case of
 M. Dieulafot, of Toulouse, who also after all  the  discussion which has occu-
 pied our pages, (see Vols. I. and II., Drs. Schmidt and Carnochan,) on the claims
 of priority for the total division of the masseter, appears  to  have been the first
 surgeon, who first actually achieved this triumph, as well as a  complete cure in the
 case in question, but not until after the subsequent partial division of the pterygoid
 muscles.
   M. Dieulafoy, according  to the  Journal de Med. et de  Chirurg. Prat., of
 August, 1839,  divided the year before (1836) by puncture in the cheek externally,
 and then by the subcutaneous method the entire right masseter  in a soldier aged  29,
 at the Hotel Dieu, Saint Jacques  (Toulouse,) in whom the muscle on  this side
 had become permanently contracted, and to such degree in consequence of scurvy,
 while with the French army in Africa, as to effect  a rigid closure of the jaw.  The
 cure was, however, not completed until the surgeon, after the  cicatrization  of  the
 wound, had divided also the anterior fibres of the pterygoid muscles, which formed a
 bridle  behind  the last  molar teeth.  (See  also American Journal of the Med.
 Sciences, Vol. XXVI.,  Philadelphia, 1839, p. 218.)
   While on the subject of the adjustment  of disputed  claims,—the preceding one
 having now we presume been put forever at rest,—we will remark, that we ha*ve
 in our notes to Vol I., taken occasion to bestow some laudation upon Dr. Mott, as
 the first person, who upon his last  return from Europe, took an  early  opportunity
 to establish at the University of this city,  and upon a secure basis, the valuable
 course of public instruction and gratuitous surgical services  to the poor, known  for
 the first time in our country,  but for several years since in Europe as  a Medical
 and Surgical Clinique.
   Dr. March,  an esteemed Professor in  the Medical  College of Albany, claims
 priority on this subject—by a year or two in advance of Dr.  Mott.   We are ready
 to concede to him all the  praise he  is  thereby entitled to.  But we will observe,
 that so far as public attendance and surgical operations, and  medical prescriptions
 for the  out-door poor soliciting advice  at hospitals, dispensaries, &c, goes, the
 matter of Cliniques (applied in an  inverse sense to the truth  so far as the etiology
 of the word or bed-side practice is considered,)  is  quite an old affair all  over the
 world, having been in common vogue for a century, or for half a century at least.
   It is a source of infinite satisfaction both to Dr. Mott and myself, to have an op-
 portunity at this late hour, of rescuing  another and more important surgical claim
 from  oblivion, by the accidental acquaintance  we made  during the past summer
 with the venerable Walter Brashear, M. D.,  for many years an eminent planter of
 Attakapas, Louisiana, and a senator 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 Uni-
 versity 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-femoral 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. (See text of M. Velpeau on this subject,  p. 637, &c.
 in Vol. II. of this work.)
   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 there-
 fore, as is seen  in his case of coxo-femoral disarticulation in Vol. II. of this work
 had hitherto supposed that he was the surgeon  who in this country had first per-
 formed 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 malig-
nity would rob and calumniate both the  dead  and the living, Dr. Mott  cheerfully
 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 gentleman to whom it rightly
belongs.
   As it may doubtless become the theme of future discussion, we  take the opportu-
nity 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. 
PREFACE.
V
                                             Philadelphia, August 13th, 1846.
   Mr 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  and Goodlet, conducted  in manner  following:—first premising,
 that in  absence of any knowledge of an  established  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 remote  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 great trochanter to the head of the bone and upper part  of the
 socket.  The dissection of the bone from the surrounding muscles, was simple and
 safe by keeping the edge of the knife resting against the bone.  The bone being
 disengaged from its integuments at its lower extremity,  was then turned out at a
 right angle from 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 operation,
 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 the operation in question was a fracture  of
 the thigh,  complicated with much contusion of the parts,  and which from bad man-
 agement or neglect, or both, resulted in the establishment  of an extensive and
 dangerous suppuration in the neighboring tissues and inter-muscular spaces.
   To another  of our countrymen and a  citizen  of New York,  Prof. John W.
 Francis, M. D., we would  with pleasure  have also devoted  a larger portion  of
 space in the body of the text than we shall in this preface have an opportunity to
 do, had not the volume already become augmented to  such size as to preclude the
 possibility  of giving the details of all the interesting and important cases of ova-
 rian and other tumors which have  occurred in his obstetrical  practice, and the
 principal part of which must be reserved for a second edition.
   Professor Velpeau, in his various valuable publications on obstetrical science, has
 with his usual discrimination adverted to the several affections with which the uterine
 system is at times invaded, and hence we may account for the omission of his elabo-
 rate disquisitions in the present work,  on the subject of the several forms of uterine
 tumors, and the disorders of the ovaria. A chapter of some extent might unquestion-
 ably be embraced in this work, on this great topic, so closely associated with medical
 and chirurgical practice, inasmuch as  the services of several of our American prac-
 titioners  and operators have shed light on  the pathology of these  disorganizations,
 and enforced by surgical  measures additional means  for the  alleviation of these
 morbid conditions.   The cases of extirpated diseased ovaria by Dr. M'Dowell,  of
 Kentucky,  as recorded  in the Eclectic Repertory, evince not less the skill than
 the intrepidity of this bold operator  of tumors connected with the uterus.   We
 may search in  vain I believe, for any instances  of so formidable a bulk as that
 recorded by Professor Francis in his  improved edition  of Denmarks Midwifery.
 The case fell  under the  observation of Professor Mott, and the circumstances
 characterizing the case are  given  in  the work just  alluded to with great minute-
ness.   The patient  was aged about 32 years : the  tumor grew from the fundus  of
the womb,  externally.   According to evidence taken at the time of the post-mortem
examination, the entire mass of  abnormal growth, including several excrescences
 attached to the  tumor itself, weighed  one  hundred  and  one pounds.   Its fibrous
 nature was evident.  Upon cutting into its substance in  different directions, a sac
was found in its right portion, out of which issued  three quarts of a purulent and
most offensive matter.  The extent of the  abdomen  of the patient, before the re-
moval of the tumor measured four feet eight inches and a half.  Professor Francis
has in the same work given other cases of fleshy tumors of the uterus ; and in the 
VI
PREFACE.
New York Medical and Physical Journal other instances of uterine affections with
extensive ovarian dropsy.
   In conclusion on the subject of reclamations, and without deeming it at all neces-
sary to pay the  slightest attention  to some puerile  and insignificant pretensions
which have been set forth and vehemently insisted upon in sundry professed notices
and maudlin criticisms on  the two first volumes, we will here barely state, that in
a respectful communication transmitted to us from Dr. Samuel S. Whitney, un-
der date of Dedham, (Mass.,) March 5th, 184(i, he claimsthe honor of having been
the first person,—and before Dr. Ruschenberger of the U. S. Navy, to whose com-
munication (see  Vol. II. of this work,) he alludes,—in this country at least—who
clearly diagnosed a case of unequivocal aneurism of the basilar artery. Dr. Whitney
says (see his case in the Oct. number of the Philadelphia American Journal of the
Medical Sciences, for 1843,) that this occurred as  early as the year 1841, and
during  the  time he was making  investigations and collecting facts in regard  to
cerebral auscultation.
   Not only has the complete exsection of one half the lower jaw, and various por-
tions of the upper maxillary bone, been long  since performed by Dr. Mott and many
other surgeons, (see text of Vol.  II.,) but also recently the exsection of the entire
tipper jaw on both sides.  This was  accomplished July 23, 1844, by a  surgeon  of
Germany, Dr. Heifelder, of Erlangen, on a male patient aged 23, for an indurated
tumor, occupying the vault of the palate, and which  had displaced and elevated
the nose, &c.  The operator made two incisions, each commencing at the great
angle of the eye, and terminating at the commissure of the lips, circumscribing
thus together a quadrangular flap, which was reversed upwards on the forehead.
Passing Jeffrey's chain-saw through the left spheno-maxillary fissure, (fente,) he
detached the maxillary bone  from the zygoma; proceeded in the same manner
on the  right side, and then separated both bones from  the  frontal, os  unguis and
ethmoid by the  same saw ; separated the vomer and other adhesions with the
scissors, and brought down and  united the  flaps by 27 points of suture.  There
was no hemorrhage or fever, and the cicatrization was complete in four days, and
the patient was enabled to swallow with ease.  Very little deformity remained, a
cleft of 15 lines only being left  on the median line  of the vault  of  the  palate,
(Walther  fy Ammon's Journal  fur  Chirurgie, t. III., f. 4, p. 633,  Arch.  Gen. de
Paris, 4e ser., t. IX., November, 1845, pp. 355, 356.)
  A new method also of curing false joints has  been proposed by the illustrious
Dieffenbach.  In a girl aged 14, (Dr. Hering, Ueber das Wiedernaturaliche, Ge-
lenk ; Berlin,1843, also Arch.  Gen., Sept., 1845, p. 100,) with a false articulation in
the leg, he at first divided the flexor  muscles, which drew the limb into an angular
projection,  viz., the tendo achillis, flexor longus pollicis pedis, and tibialis anticus,
and then by means of two or three very narrow incisions leading down to the bones,
applied a small perforating trephine, which he worked drill-fashion, as in lithotrity,
till he had  made 5 to 8 holes through the  morbid osseous  parts  and their connec-
tions.  Rapid  cicatrization and perfect restoration of the limb followed  a short
confinement of the limb on a wooden gutter.
  The diagnosis of substernal aneurisms (see Vol. II.,) is not the only one which
has baffled the acumen of the most eminent surgeons now living in the practice of
the stethoscope and auscultation.  Even the fingers, and most refined sense of touch
that can be acquired by long  habitude with morbid growths, are frequently found
to lead to the-most humiliating results as interpreters of the real difficulties that exist.
We have in this volume alluded, under the head of  Hematocele, to the deductions
made in one recent case, by the  singular tremulous or oscillating, or gelly-like sensa-
tion of fluctuation imparted to the touch, and which after the operation was discov-
ered  to have proceeded from  the  coagulated or clotted condition of the contained
sanguineous fluid.
  In a recent successful extirpation by Dr. Mott, of a remarkable tumor involving
the entire mamma, and of the rapid  growth of only 8  months, in a married  woman
aged about 50, and the uniform ovate or oblong spheroidal shape of which, of the size
of a foetal head at full term, was one remarkable feature, we saw a similar scene of
embarrassment.   Almost every person present was satisfied of a clear fluctuating
limpid fluid in large quantity within the malignant production.  Dr. Mott, as usual
was slow to express an opinion,  and waited  for the demonstrations of his unerring
Bcalpel.  The story was soon told, and we think to the astonishment of all. 
PREFACE.
Vll
  There was first a regularly formed outer  tough fibro-membranous covering of
considerable thickness:  next came another stratum an  inch thick, of hard semi-
transparent, homogeneous gelatino-albuminous tissue, (similar to what is sometimes
seen in the hypertrophy of the bronchial glands at the bifurcation of the trachea,)
and finally, within,  and  close and next to this last, and forming the central nucleus
of the tumor, and about three inches in diameter, a red, semi-transparent globose
mass of softest friable coagula apparently, and no doubt in fact the residuum of an
ancient hematocele,—but no  water any where between  these strata or none to
speak of, sufficient  to convey the  slightest degree of hydropical fluctuation pro-
perly so called.   It was the coagula, or as I conceive  the debris of coagulated fibri-
nous blood that imparted the deceptive sensation of fluctuation, and which fluctua-
tion was in truth, as far as my own examinations went, precisely of the tremulous
or oscillatory character already mentioned.
  It was our intention, but for the size of this volume to  have inserted  under the
article of laryngo-thyroidean bronchotomy, a highly important case, in which a large
shawl or hair-pin near two and a half inches long, and with a head the third of an
inch in diameter, and lying with  its  head upwards, and  playing up and down in
the larynx, was successfully extracted by Dr. Mott, from a child aged about three
years,  the daughter of Lieut. Governor H----, of Connecticut.  We have how-
ever, in a note (p. 656, 657, vol. I.) alluded to the important and neglected practi-
cal point to be attended  to in such operations, especially in children, viz. the dan-
ger of cutting carelessly down into the air passage  through the engorged tissues,
and the necessity of guarding with the utmost  precaution against the slightest ad-
mission of blood into the respiratory tube.
  We could also have expatiated upon the recent, still more remarkable operation,
in which a gold piece of coin, viz., a half sovereign,  was by an ingenious contriv-
ance of Sir Benj. Brodie in inverting the body, successfully removed from the la-
rynx of a son of  Mr. Brunei the celebrated English  engineer, after all hope of re-
covery almost had been extinguished.  This case however, has been so frequently
detailed in the principal  publications both in Europe and America, that the mere
allusion to it at present may suffice, until the opportunity shall present of another
edition of this work. We  will now, until such event may arise, bring this work
to a final close, with the single expression, that  my respected associate and myself,
can both conscientiously declare, that without  fear or favor, we have endeavored,
to the utmost of our ability, to fulfil in a proper manner all that we promised,  and
to present to the profession,  to the practitioner as well as to the student, a complete
and systematized elementary treatise on Operative Surgery, embodying all its most
valuable history and processes down to the present moment, in such purity of dic-
tion, and upon principles so orthodox, that it might be  deemed worthy for a long time
to come, to occupy  a permanent rank in the hands of every person devoted to  this
now-absorbing and  most clearly-defined department of the healing art.
                                                                  P. S. T.
  New York, February 2d, 1847. 
 
            NEW  ELEMENTS

                       OF

OPERATIVE  SURGERY.
                        CHAPTER  III.

               DISEASES  OF THE  MOUTH.

                   Article I.—Lips.  § I.—Harelip.

   The labial fissure known under the name of harelip, is either acquired
 or congenital.  That which takes place after birth is noticed almost as fre-
 quently upon one lip as upon the  other; the congenital, on the contrary,
 up to the present time has rarely  been observed except on the upper lip.
 The facts cited by Meckel and Nicati, who profess to have seen it on the
 lower lip, are truly exceptions.  Since Louis maintained that the harelip
 is not  accompanied with any loss of substance, Blumenbach, Tenon, Be-
 clard, Meckel, etc., have endeavored to explain its formation according to
 certain laws of the organism, and  to show that its different modifications
 were the result of an arrest of development, (arret de developpement.)
 Three portions, according to some, constitute the  upper lip in the begin-
 ning, a median and two lateral.  There are even four, according to others
 who maintain  that the middle part  is also divided primitively into two.
 According  to  this hypothesis simple harelip is owing to one of the em-
 bryo fissures of the lip having persisted, and the proof of this,  they say,
 is that it is  almost  constantly found outside of the median line.  When
 the  two  lateral parts remain isolated from the middle part the harelip
 is necessarily double. If the authors of some observations already ancient,
 and  more recently Moscati, were  not deceived, and if they have really
 seen the  harelip placed  exactly  in continuation with  the septum of the
 nose, it could be explained by admitting the non-union of the two halves
 of the median lobe of the lip.  Finally, at the lower lip, where, as in the
 case of Tronchin, (Petit, Dissert,  sur le bec-de-lievre, p. 5, 1826, Stras-
 bourg,) it induces marasmus by the loss of saliva,  the congenital harelip
 must always occupy the median  line, because in its formation they say it
 never has more than  two portions.  Numerous researches on embryos
 and the foetus at every period, induce me to believe that these ideas are the
 result of erroneous observations or gratuitous suppositions.  Harelip is not
 always without loss of substance, and the lips  are no more formed of two,
 three, or  four portions, at three, four, six,  or eight weeks, than at three
 or four months. As soon as we see them begin to point they appear to be
 entire, like the buccal aperture that they accurately encircle. The contrary
 happens only by accident.  Harelip, like  most  other monstrosities,  has
 appeared  to me to be much more  frequently ascribable to some disease
than to a  defect in its natural evolution.  This  doctrine which I endeav-
ored to disseminate since 1825, counts at the present time powerful advo-
cates.  I see with pleasure for example, that M. Cruveilhier fully adopts
it.  If he promulgates it as his  own, it is  probably because he has not
taken notice of what I have said of it in various places in my publications,
especially in the first edition of my Tocolo'gy^ and of this present work.
  VOL. III.                      1 
2
NEW ELEMENTS OF OPERATIVE  STJRGERY.
   A. Simple Harelip.—1. Analysis of the methods.—Though hare-
lip is one of the most common deformities of infancy, it has never-
theless attracted but very little attention from the ancients.  Celsus,
who was the first to mention it, speaks of it however quite obscurely.
The Arabs make but slight allusion to it, and  everything goes to
show that up to the time of Franco or Pare\ its treatment had not
been the object of as much attention as  it merits.   At the present
time, however, this is a point of practice  which seems to leave no-
thing to be desired.   To  effect  the  cure  three  indications are to be
fulfilled.   Its borders  are to be abraded, its two sides approximated,
and the two lips of  the division maintained in  perfect contact until
they have become agglutinated.
   a. Abrasion.—It  was with the hot iron that Abu'l Kasem, as well
as Ludovic, effected the  abrasion of harelip.   Butter of antimony,
or  some other chemical  caustic,  was  preferred by  Thevenin,  and
Hunter made use of nitrate of silver.  Chopart,  yielding in this mat-
ter to the advice of Louis, considered that he would  succeed better
by applying upon the  borders  of  the fissure which he wished to in-
flame, two  strips  of blister plaster.  Such means could not have,
and in fact have not  produced  any but imperfect results, and have
properly been abandoned.   Excision only, which had already been
in use in the time of Celsus and Rhazes, is allowable at the present
day.  In order to effect it, D. Scacchi and Dionis made use of  the
ordinary scissors, and Henckel of  blunt-pointed scissors,  (ciseaux
boutonnes.) •
  M. A. Severin and Acrel, on the contrary, gave an exclusive pre-
ference to the bistoury, which Louis and Percy endeavored to bring
into general use; while Roonhuysen, De  Home, Le Dran, and B.
Bell, had recourse almost indifferently to the one or to the other "of
these two instruments. The partisans of the bistoury maintain that
it produces less pain, gives a neater wound, and  one that is  less dis-
posed to suppurate;  that the scissors cutting much more by a press-
ing than by a sawing movement, contuse the tissues and make a bev-
elled wound, or one  with a  double oblique  plane, which is  but little
favorable to immediate union.  Experience has a thousand times
demonstrated  the slight  foundation there is to these objections.
Bell being  desirous  of ascertaining  the fact, operated  on one side
with the scissors, and on  the other with the  bistoury, without  ap-
prising any person of it.  The patient, first embarrassed in civinc an
answer, ultimately declared that the pain  had been  more acute at
the side  upon  which the bistoury  had been used.   The scissors
adopted in preference by Van Home, (Introd. Method de la Chir.'
Severin, Med. Effic, S. 28,) Lombard, (Clin. Chir. relat. aux Plaie's
p. 38, 1802,) &c, have the advantage of requiring no point  d'appui'
and of instantly dividing every thing that we wish to remove.  De-
sault, who earnestly defended them, recommended that they should
be  very thick, and  that  the  blades  should be strongly  sloped
Those which are preferred  at the present day,  and which bear the
name of those of A.  Dubois, are constructed upon this principle.   In
order to  increase with greater  effect the  power which is to move
them, a great relative length is given to their handle.   Their  blade
which is short  and solid, in this manner cuts with all the  precision 
LIPS.
3
desirable.  It would be an  error, nevertheless, to  conclude that the
bistoury would not answer.   As to the manner of its employment, it
has singularly  varied.  Le  Dran, imitating Guillemeau, began by
plunging in its point through the lip from the mouth towards the
skin, a little above the summit of the division, and afterwards divided
perpendicularly from above downwards, or from behind forwards, as
far as to the labial border, doing the same afterwards at the opposite
side.  B. Bell adopted a course directly the converse of this.  Placed
behind the head of his patient, with the  bistoury held  as a  writing
pen, he made his  incision set out from the free border of the  lip, and
extended it from below upwards and from before  backwards as far
up as above the summit of the abnormal fissure.  Enaux, after having
destroyed the folds and adhesions which unite the alveolar arch to
the lip, glides behind this last a piece of cork, upon which he recom-
mends that the lower angles of the harelip should be  supported, in
order that the bistoury may  thereby be furnished with  a point d'ap-
pui.   In place  of the cork,  recommended by Enaux, we  generally
confine ourselves to a piece of pasteboard, or simple playing-card, or
portion of soft wood.   The forceps, or morailles, either of metal, like
those of J. Fabricius and  Lauth,  (Erhmann, Dissert, sur  le bec-de-
lievre,) or of wood, like those used by M. A. Severin, which served to
fix the lip while its exsection was being made, which by the  greater
breadth of their posterior  branch, could replace the  piece of paste-
board which the use of the bistoury required, and which also had for
their  object to  aid the approximation  of the  two abraded borders,
and  to prevent hemorrhage,  have been long since rejected from
practice.   Heister, Acrel, and B. Bell are, I believe, the last authors
who have thought proper to recommend them.
   b. Reunion.—After the abrasion of its borders, the harelip is founL
reduced to the  condition of a simple wound, and its immediate re-
union is to be attempted either by means of suitable bandages or the
suture, or by combining those two modes together.   Franco, who con-
fined himself to plasters fixed upon the cheeks, and small  strips crossed
under the nose, in order to make  what he called the dry suture,  then
by a containing bandage; F. Sylvius, who, according to Muys, suc-
ceeded with the adhesive plaster  alone, also supported by a bandage,
and Purmann and G. W." Wedel, who, it is said, were not less fortunate,
found in Pibrac, and especially in  Louis, a warm defender.   Accord-
ing to this author, the bloody suture is not only unnecessary,  but also
injurious.   Unnecessary, because the harelip  being unaccompanied
with any loss of substance, it is always practicable to  effect its ap-
proximation by means of the uniting bandage for long wounds ; in-
jurious, because its presence is a permanent source of irritation, which
cannot fail to bring into action the muscular retraction.  Following
out this principle, Louis used only a  single point  of  interrupted su-
ture, and to complete  the reunion employed  a simple band.   The
ideas  of Pibrac, who desired, so to  speak, to proscribe the  suture
from surgery, appeared to find in this operation a judicious application.
Valentin, in'order to effect a more perfect coaptation, devised a clasp
or sort of double flat forceps, capable of embracing the two sides of
the wound, and of being  approximated  at pleasure  by means  of a
transverse  piece  and screw.  Enaux, (Acad,  de Dijon, 1783, t. 11., 
4
NEW ELEMENTS OF OPERATIVE  SURGERY.
 p 220,) in order to avoid the contusion and unequal compression made
 by the instrument of Valentin, proposed a bandage, the model, of
 which exists in the museum of the faculty of Paris, and which by
 being attached  by as many circular arcs at the top of the  nape, at
 the vertex, and under the lower jaw, presents two pelotes which are
 intended to push the soft tissues forward, when they are applied upon
 the cheeks, and which  may be reunited  in front of the wound by
 passing a strip from one to the other.
   Evers  rejects all these modes, and confines  himself to two adhe-
 sive strips, which  he crosses obliquely (en sautoir) below the nose.
 M. Dudan has since invented, with the same object, a new clasp based
 upon the principle of that of Valentin.  For another we are indebted
 to  M. Montain, (Therapeut. Med. Chir., &c,  1836, p. 16,) who as-
 sures us that he has made use of it with advantage  both in children
 and in adults.   Brunazzi (Gaz. Salut., 1792,  p. 294, 12 July,)  Gi-
 raud St. Rome (Soc. Med.  de Marseilles, 1811,  p. 23, ) and M. Kluy-
 kens (Bull, de la Fac. de Med., 1811, p. 184,) have also obtained suc-
 cessful results with the contrivances of their invention.   There is no
 doubt  that in this manner we may sometimes cure harelip ;  but  it is
 incontestable also, that in the majority of  cases the reunion is  badly
 and imperfectly made, and that there  frequently remains a groove
 either  in front or beh'nd, and at the lowermost  part a notch almost as
 disagreeable as the first disease, while the bloody suture, if properly
 adjusted, protects us from all these  inconveniences.   It  is also  the
 one which is exclusively used in our time, and the bandages, inclu-
 ding that  of Terras, (Lassus,  Med OperaL, t. II., p. 388,)  are no lon-
 ger recommended except as accessories.
  c. Celsus, who sewed up the harelip, does not give sufficient details
 to enable  us to understand what kind of suture was employed in his
 time.   It  is probable from what Albucasis says of it, that the glover's
 suture was the  one made  use of by the Arabs.  Others, as  Heuer-
 mann,  Ollenroth, and W. Dros, for example  have recommended  the
 interrupted suture, which was also  preferred by Lassus, in order  not
 to be obliged to leave inflexible metallic stems in the wound.   There
 is no kind of suture, even the quilled, which has not had its partisans
 though the twisted suture is the one which has been almost  alwavs
 preferred.  In order to have a kind of twisted suture, M Van Onse
 nort places upon each  side of the  borders of  the wound a narrow
 ivory plate pierced with three holes ; having introduced his threads
 with an ordinary needle, he knots them on the  plate on the Wt «;d0
 M. Mayor (Gaz. Med., 1838, p. 737,) recommends one or  two do  n^
 of suture  attached to  (entrainant), a roll of lint or cotton  and  wh  h
 are to  be fixed upon a similar border.  A. Pare, the first'author who
 describes  it m  exact language, made use of the twisted suture  h
 means of needles  furnished with eyes, and which he inserted f-  ^
 one side of the  wound to the other, and afterwards fixed by m r°m
 of turns of thread  passed in a figure of 8 round their extremitie^*1*3
  d. Fabricius  ab Aquapendente employed flexible needles, the \
 tremities of which, after having inserted  them, he  bent forward*"
Those  of Roonhuysen were angular or triangular, like those of Pa •-*'
He  surrounded  them with a  thread of silk and cut off their po'^
with the cutting pliers.  Dionis recommends that they should be tf 
LIPS.
5
steel and curved.  La Charriere, in place of clipping off their points
like. R.oonhuysen and Dionis, used  only a small compress between
the skin and their extremities.  In order to  introduce them without
difficulty, notwithstanding their  small  size, Heister made use of a
needle handle, and  J. L.  Petit, who made them  still stronger, and
provided each of their two extremities  with  a head, fabricated them
of silver and  conducted them by means  of a  sort of punch.  Le
Dran  preferred that they should be of gold, in order that they might
be at  the same time very solid, though sufficiently firm, and not oxydi-
sable, and that they should  have a flattened point and be provided
with a head, to avoid the  employment  of a needle handle.   If gold
and silver possess the advantage of not rusting, they also have the
inconvenience when  we wish to  make  cutting  instruments of them,
of not penetrating as easily through the tissues.  In consequence of
this, Sharp proposed to solder upon his  silver needles a spear-shaped
steel point.  Wedel asserts that  ordinary needles are  sufficient, and
that we should  surround  them afterwards with a  hempen  thread.
De la Faye maintains that without having recourse to so much pre-
paration, strong  long copper pins, in a word, German pins, are pref-
erable to all others.  As their point might wound the patient, Mursinna
recommends to protect  it  afterwards by means of a small piece of
quill.   Le Dran had found  it  more convenient  to make use, for
this purpose, of  a small  ball of wax.  Arnemann  (Sprengel, t. VII.,
p. 136), had them hollow, the head and point of which might be re-
moved at pleasure.   Those of Desault, which  are  of silver with a
steel  point, are made so as to diminish  in volume from their cutting
extremity to that which is to  support the action of the finger, in or-
der that they  may be extracted  without bringing them  back again
through the same track  that they have  entered, and without  passing
their cutting portion  a second time through the flesh.   These are the
ones which in  France at least have been almost universally adopted.
We cannot see indeed that  there is any objection to  them unless it
be that  ordinary pins, such as are everywhere met with, may not-
withstanding be wholly substituted for them, if  before inserting them
we take the precaution to sharpen their  point a little, in order to
flatten it by rubbing  it against a tile in the  apartment, or  some stone
vase or any hard stone.
  e. The semilunar incisions, with their concavity forwards, which
Celsus made  on the inside  of  the cheeks,  and which Guillemeau,
Thevenin, and Manget,  made on the outside, and  the  dissection and
gashes on the  posterior surface of the lip which Franco,  (Traite des
Hernies, &c, p. 460, 1561,) J.  Fabricius and D.  Scacchi  recom-
mended in order to favor the approximation of the borders of harelip
are no longer to be mentioned  in  simple cases,  except to  expose
their absurdity and  barbarity.  I have mentioned in the chapter on
anaplasty under  what circumstances they may be useful.  But this
does not apply to the suggestion of preparing  beforehand the parts
which are to be approximated.  In place of the pincers of Fabricius,
&c, V. D. Haar, and after him Arnemann and Knackstedt of Peters-
burg,  have recommended  a  bandage which, after having been em-
ployed for a week or two, is capable of approximating towards the
median line the points which it is important for the operator to bring 
6
NEW ELEMENTS OF OPERATIVE  SURGERY.
 into contact.  It rarely happens, however, that the moderns consider
 themselves  obliged to follow out  this indication, inasmuch as they
 know that an ordinary uniting bandage would perfectly attain the
 same object.  Unless the separation should be extreme, the immedi-
 ate approximation of the sides of the wound is usually attended with
 but very little difficulty.
  /. Surgeons at different epochs,  apprehending that in spite of the
 suture the parts might ultimately retract, have endeavored  to find
 some means of obviating this  inconvenience;  from whence is de-
 rived  that multitude  of dressings with which  the  science is over-
 charged, and that combination of the dry  suture or bandages with
 the bloody suture.  In this respect Dionis is the one who appears to
 have given the example.   He  placed an  agglutinating  plaster in
 front of his twisted sutures, and supported the whole by means of a
 bandage with four tails.  La Charriere considered that by means of
 a circle of steel, which surrounded the head, and by graduated com-
 presses which he placed upon the cheeks, success would be unavoid-
 able.  It was for the purpose of replacing his bandage, as modified
 since in various ways  by Quesnay, Heister, Henkel, Koenig,  Stuck-
 elberger, Eckhold, &c, that Enaux and Valentin devised those which
 bear their name, and that M. Roux (Med. Oper., t. I., p. 451) associa-
 ted with  the ordinary  suture a square  piece of adhesive plaster, pro-
 vided with nooses of thread on each cheek, but which  the bandage
 of Louis or that of Desault have caused to be entirely abandoned.
  II.  Operative Process.—As to the rest, the following is  the mode
 to be adopted in the operation: the different articles are composed
 of an erigne, a claw or dissecting forceps, a pair of harelip scissors,
 three, four or six prepared  needles, a simple waxed thread two  to
 three feet long, a second thread composed of two to three strands
 and twice as long as the first, small rolls of  adhesive plaster or linen
 to place under the extremities of the needles, a thin plumasseau of
 lint besmeared with cerate, two compresses somewhat longer than
 broad, and folded six or eight double, to be applied upon the cheeks
 a band an inch wide and rolled  into two heads and  sufficiently lono-
to make four or five turns  round the head, the sling bandage, strips
of adhesive  plaster in case we do not  wish  to employ a bandage a
 playing card, and a straight bistoury when we do not wish to operate
 with the scissors.
  a. First stage.—The patient  being  placed upon a chair in  a well
 lighted apartment,  is  to  have  his head steadily supported  by  an
 assistant, who is  to prepare himself in  such manner as to be enabled
to compress at the  same time the external maxillary arteries  below
 and in front of the masseter, to push forward the cheeks towards th
median line, and to hold the lip if it is necessary, while  the  operat 6
 excises it.  A second assistant is charged with handino- all the diff0'1"
 ent  articles  according as  they are required.   The surgeon  be^o-
 seated or standing up in front of the patient, passes a thread through
the  lower left angle of the division, as Koenig recommended, should
 he not prefer to  introduce  there a pin  or hook it up with  an' eriffne
as M. Roux does, or more  simply make use  of the tooth forceps as T
do, or of the forefinger and thumb, in order  to secure it  with the left
hand.  The scissors being  held in the other hand, are  immediately 
LIPS.
7
carried to two or three lines higher than the upper angle of the
Assure, and separate the whole rounded  portion with a singe cut, if
possible, encroaching even  a little upon the sound tissues in  such
manner  as to  make  a fresh, straight, regular, and  neatly incised
wound.  On the other side he stretches the lip itself by embracing
or drawing upon it with the thumb and forefinger placed a little out-
side of the border which is to be exsected.  The scissors, which are
to be directed as before, are to be raised  at \heir point as high as the
upper extremity of the first wound, and even a little higher, in order
that the two strips which have been isolated, and which, by their re-
union, represent  a V reversed,  may  be  found at  the moment free
from every adhesion, even at their nasal angle.  Nevertheless,  if at
this point a pedicle should remain, it should be divided by a third cut
of the scissors, and as high up as possible.  Otherwise this part of
the wound, being too much rounded, would not allow of an exact
coaptation  without difficulty.
  b.  Second stage.—In order to insert the suture, the operator again
seizes the right side of the solution of continuity with the forefinger
and thumb of the left hand.  With  the right  hand  he directs the
point of  a  first needle upon the skin, at half a line above the vermil-
ion  border of the  lip, and at three lines external [to the wound];
plunges it  in somewhat obliquely from below upwards, from before
backwards, and from the skin towards  the mouth, in order that in
traversing  the tissues it may come out at the union of the two ante-
rior thirds with  the posterior third of the  bleeding  surface ;  then
changes  its direction ;  pushes it through  the other lip, from behind
forwards, from above downwards, and from within outwards, in such
a manner that its place of entrance and exit  may be as accurately
upon the same line as possible, and that in its whole track it  shall
have made a slight curve whose convexity is directed  slightly back-
wards and  upwards.   Its two extremities are immediately encircled
by  the simple noose of thread, prepared  for this purpose, and which
enables the assistant, who is charged  with this, to stretch in a proper
manner the whole extent of the lip, while the surgeon inserts the se-
cond needle.  The latter needle, if" we want but two of them, should
be inserted at an equal distance from  the  first and  the  upper angle
of the harelip.   There is no  necessity, as with the other  needle, of
making it describe a curve or traverse separately through the two
halves of the division.  It is therefore pushed in  transversely  with
the right hand, while the fingers of the left hand hold the two  bor-
ders of the wound in coaptation, taking care nevertheless to make it
enter and come out upon the skin at about three lines  from the solu-
tion of continuity.  In making  use of fine pins,  of  insect  pins for
example, I have often employed as many as five with advantage.  The
middle part of the  double  thread  seizes the last immediately after.
Conducted  by the two hands the two  halves of this  thread envelope
it afterwards with cross turns in figure of 8, are then brought for-
ward by forming an X under the adjoining needle, which is sur-
rounded in  the same manner, and thus in succession from one to the
other, until  the thread is exhausted or  the whole wound is concealed
by the figures of 8 and X which it has furnished.  To terminate this 
8            NEW ELEMENTS OF OPERATIVE SURGERY.
 operation its two ends are rolled up, in order to  be fastened  under
 the head or point of the upper needle.
   c.  Third stage.—The first thread having become useless is divided
 by the surgeon, who then places small protecting rouleaux between the
 integuments and the pins, together with the plumasseau of lint, and the
 adhesive plaster  or  bandage, if he  has concluded to make use of
 them.  In this case he applies the middle of the bandage on the mid-
 dle of the forehead ; carries the two heads under the occiput, crosses
 them and changes hands, brings them back below the ears, and upon
 the square compresses which the assistant maintains in  front of the
 masseter muscles ; arrives on the sides of the nose ; makes  a slit in
 one of the heads of this bandage, opposite to  the wound, in order to
 insert the other there, and to cross  them with greater facility  ; car-
 ries them back above the nape in order to cross them a second time,
 and to terminate by circular turns  around the cranium.  The sling
 bandage, which is to fasten the whole, is  first applied to  the  chin by
 its middle portion.  The two  lower heads are then raised up in front
 of the ears,  over the cheek compresses, and  as high as the vertex,
 where they  are attached. The two anterior heads which remain are
 to be  carried backwards in order to  cross at  the occiput, and  to be
 brought forward  upon the forehead.  At  present, however, I dis-
 pense  with  every kind of bandage  and find I can get along very
 well.
  III. Subsequent treatment.—This  being done, the patient is  to be
replaced in his  bed, where he is to remain at rest without speaking
or attempting the slightest movement of the jaws, during the space
of three or four days.  Broths and very light  soups, weak wine and
water, or any ptisan whatever, constitute his whole diet.  At the ex-
piration of three days, if everything goes on  well, the upper needle
may be removed ; and on the  fourth  day that  also  below.  The
mass of nooses of thread, glued to the skin, and left in place for one
or two days longer, enable the cicatrix to  gradually consolidate.
When the front part of the lip is entirely freed of them, we may sub-
stitute adhesive plaster, if any apprehension exists that the reunion is
not yet sufficiently firm. About the ninth or tenth day the cure is usu-
ally complete.  There will  be no impropriety in  beginning on the
fourth to allow of soups somewhat more substantial, and to permit
the patient to get up and walk.   When  the needles are fine  and in
greater number, they may be withdrawn much sooner, beo-innino- on
the day after the operation.   They have not, to  the  same°extent as
the others, the inconvenience  of ulcerating and of mortifyino- the tis-
sues which surround them.
  IV. Remarks.—Before commencing   the  operation it is  almost
 always  necessary to divide  the frenum of the upper  lip.   It
 scarcely be dispensed with when we make use of the scissors, exceot
in cases in which the fissure has but little depth and is situated out
 side of the  median line.   The  bistoury forms no exception to this
 remark unless we dispense with giving it a support.  When usine
 this latter instrument we place, after the frenum has been divided  a
 card as high up as possible between the maxillary bone and the lip
 After having fixed, by embracing it at  its lower angle, the left bor-
 der of the harelip upon this  card, we direct the point of the instru- 
LIPS.
9
 ment, held as a writing pen, to the spot where the incision is to begin,
 in order to plunge it in perpendicularly, then gradually to depress its
 handle and to cut with a single stroke the whole extent of the fleshy
 border included between the cutting edge of this instrument and the
 card which hinders it from penetrating into the mouth.  In order to
 excise  the other border the surgeon seizes hold of the lip  outside of
 the division,  unless he should  be sufficiently practised to do with the
 left hand what he has done on the opposite side with the right hand;
 carries in every case the point of the bistoury  to the upper angle of
 the first wound, and terminates the incision  moreover on this side in
 the same manner as in the other.   The compress  which Lavauguyon
 placed between the lip and the gum, in order to prevent the adhesions
 of this  last, already rejected by Le Dran as useless if not dangerous,
 and again proposed  by Heuermann, is no  longer employed at the
 present day  by any person, any more than is the  piece of sheet lead
 advised for the same purpose by Eckholdt.   Cases where the lip has
 been separated to a great extent  from the maxillary bone  are the
 only ones which would allow of its being thought of.  De la Faye
 and Mursinna, who recommend that we should commence with the
 highest needle, doubtless forgot that in that event the two labial ex-
 tremities of  the  division incur the  risk of not continuing upon the
 same line.  De la Faye himself was obliged afterwards to exsect the
 deformed tubercle, which was the result of  it in one  of his patients.
 Without conforming  entirely to the precept  of  Le Dran, or plunging
 the lower needle into the vermilion border of the  lip, we ought how-
 ever to recollect that at the distance of  more than a line above it
 the  reunion  might not be complete and  might leave a small notch
 below.   If it did not penetrate nearly as far as to the buccal surface
 of the organ, the agglutination would be  effected only in  front.  A
 groove or gutter of greater or less depth would continue behind, and
 render  the success of the  operation  imperfect.   The  bleeding  sur-
 faces not being in accurate contact,  nor  pressed together in a uni-
 form manner throughout their whole thickness, would  favor hemor-
 rhage.  It is readily perceived, on the other hand, that there would be
 a disadvantage in traversing  the two halves of the lip through and
 through.  In making the needle describe an arc the object is to depress
 the tissues a  little more  upon the median line than upon the sides, in
 order thereby to reproduce as much as possible the tubercle or small
 projection which  should naturally exist there.  The curved or flexi-
 ble needles would be  incapable of fulfilling this  indication, which has
 been  particularly recommended  by A.  Dubois  (Heurtault,  These,
 Paris, 1811.)   Although, as a general rule, we  should  excise  rather
 a little more than less and prolong the wound, as  B. Bell has pointed
 out, as high up nearly as the nose even when the notch has but  little
 depth, it will  be found sufficient however, by removing the whole red
 portion or cicatrized border, to transform the harelip into  a fresh
 wound with loss of substance, of an exact triangular shape, and the
 edges of which present  in every part the  same degree of thickness.
 It would however,  perhaps, be well to make each border  of the
division concave, as recommended by M. Husson, the son, (These,
No. 185, Paris, 1836,) should  it appear that the reproduction of the
middle tubercle of the lip would without this expedient be attended
  vol. in.                      2 
10
NEW ELEMENTS OF OPERATIVE SURGERY.
 with  too  much  difficulty.   If the effusion of blood, which  at  first
 comes out with considerable force from  the coronary artery, should
 not yield to pressure made on the facial artery on the border of the
 jaw, the assistant in order to arrest it would only have to pinch the
 corresponding half of the lip.  Neither the ligature nor caustic are
 ever indispensable in these cases.  As soon as the two bleeding bor-
 ders are brought together the hemorrhage ceases ;  their want of con-
 tact in one point or another, or some unforeseen accident, could alone
 enable it to continue.  The surgeon moreover would  be censurable
 not to pay attention  to this subject during the  first hours, especially
 in children.  The blood, in fact, in place of being expelled outside,
 is swallowed  by  them in proportion as it oozes into the mouth,  and
 as  Platner says, the  hemorrhage in this manner may  go on to some
 degree unperceived,  or  may even, as in the examples  given by J.
 L.  Petit  and Bichat, proceed to such  extent as to cause  death.   Be-
 fore applying the bandage  it is well to cover the head with a cotton
 cap, drawn down so  as to prevent its  being disturbed without some
 difficulty ;  also to comb out the hair well and to besmear it with
 mercurial or veratrum (cevadille)  ointment, in order to  prevent the
 necessity of scratching, which young patients could not resist should
 vermin make their appearance on the  cranium.
  The two compresses, which are placed in front of the ears, possess
 the triple advantage of crowding the  tissues forward, rendering  the
 bandage more supportable to the other parts of the face, and prevent-
 ing the movement of the cheeks.  Instead of making a slit in one of the
 heads of the bandage, to pass one within the other at the point of the
 wound, we may, if necessary, limit ourselves to crossing  them care-
 fully below the nose.   The important point is, that they should  not
 make any folds, and  that the pressure  which they exert should be as
 uniform as it is gentle.   Louis cut  the free extremity of his bandage
 into three strips of from  fifteen to eighteen inches  lono-, and also
 made in them three button-holes at nearly two feet  beyond, with  the
 view of effecting a more uniform and firm crossing opposite to the solu-
 tion of continuity.  Desault, on the contrary, rolled up his only in a
 single head, fixed  it by a circular turn round the cranium, and when
 he had brought it  as far as to  the labial angle on one  side before
 carrying it back to the occiput, he strongly drew towards him all the
 soft  parts of the  opposite side, by means  of the  cheek compress
 which  without that  precaution would have incurred the risk  of
 being  pushed  backwards, contrary to the  intention of  the opera-
 tor.  But  the ordinary  bandage,  whatever Bichat  may say  of
 it, has fewer inconveniences, while  at  the same  time  it  retains the
 same simplicity as that  of Desault.  The sling  bandage generally
 used is a very useLl  auxiliary  in  certain cases.  By resisting the
separation of the jaws, it favors  the action of the  suture.   When we
recollect  that  in  a patient of Garengeot, a burst  of  laughter was
sufficient to disunite the wound ; and that a young boy operated upon
by De  la Faye experienced the same accident in consequence of  his
sneezing, from a person  taking a pinch of snuff near  him, we may
well be permitted  to do all in our power to prevent the slightest
movement  of the mouth.  In withdrawing the ordinary  needles not
 intil the expiration of five or six days,  as is recommended by Garen- 
LIPS.
11
geot, after having removed the threads, we have reason to apprehend
that we  may transform the track of the wound  into a suppurating
ulcer, and retard the ultimate cure.  If they are taken away on the
day after, or the day after  that, as Le Dran assures us he has done
without any inconvenience,  it  is  almost certain that in the majority
of cases the i-eunion will not be maintained.   Moreover, not having
yet had time to excite suppuration around  them, their extraction then
would not always be unattended with difficulty.  In  every case,
when we are about to withdraw them, it is  advisable to grease with
butter, oil, or cerate,  the  extremity which is to pass through the
tissues in coming out, that is to say, the point  for the needles which
have heads, and the blunt extremity for the others.  They must be
drawn out gently,  and  without shaking, turning them upon their axis
as soon as any resistance is made, and constantly furnishing to the
corresponding side of the lip, while we are  removing  them, a point
d'appui with-the forefinger  of one hand.  A  small quantity of lint
spread with cerate and some lotions of vegeto-mineral water are all
that is required for the subsequent cure of their punctures.
  B. Complicated Harelip.—I. In the double  harelip two different
conditions may be encountered if the vault of the palate does  not
participate in the deformity.   Sometimes  the  two fissures are  only
separated by a narrow and  slightly projecting tubercle, which must
De  removed by comprising it in the angle of reunion of the two
excisions, which have been made in order to raw  the ordinary hare-
lip.  Sometimes, on the  contrary, this tubercle is  too  large to be
destroyed without  inconvenience.  In such cases, whether it  descend
or not down to a level with  the border of the lips, it is  better to  ex-
cise its two sides.  We then pass through it  all the needles in  the
first case, and the highest, or two  highest only  in the second, in order
to attach it  to the middle of the suture.   This method, which is the
most ancient of all, is at the same time the most simple, prompt and
certain.  If, however, the middle  flap is very wide at its base, we
may, after  having embraced it at  its summit with  a first needle,
traverse  it with one or two others on each side, as M. Gensoul does,
and as I have done in one instance.   After the cure the cicatrix re-
sembles a capital Y,  and  represents alio the  track of the naso-labial
columna.  It is scarcely  perceptible to the patient that he has been
made to  undergo two operations in place of one.  He soon recovers,
and the consecutive inflammation is neither more nor less active than
that which follows simple  harelip.  The  idea, therefore,  advanced
by  Louis or by Heister, of operating  on  one  side only at first, and
waiting for its complete cicatrization before proceeding to the other,
though imitated since by  some practitioners, has not been and ought
not to be adopted.
  II. The deformity, however, is sometimes much more complicated.
It was so extensive  in a worker in gold wire, mentioned by Covil-
lard, (Obs. Iatro-Chirurg.,  p.  86, obs. 29, 1639,) that there was a
separation of two  fingers'  breadth on each side.  The portion of
maxillary bone which supports  the  middle  flap,  makes, in  certain
cases, a  considerable projection forward.  Like  Dupuytren, (Gaz.
Med. de  Paris,  1833, p.  6,) I  have in such cases  seen the raised up
lobule continuous with  the  end of the nose, and projecting directly 
12
NEW ELEMENTS OF OPERATIVE SURGERY.
forward.  Whether it coexists or not with a double division of the
palatine vault, we must attend to the complication before proceeding
to the rest  of the  operation.   Franco  (Traite des Hernies,  &c,
chap.  120,  121,  p.  460  et  suiv.) at first,  then D. Ludovic, and
afterwards Chopart and many of the moderns, have proposed to re-
move it  either with the small saw or cutting pliers, or gouge and
mallet, after having isolated the soft parts from it.   Desault having
remarked thnt this  excision leaves a void behind the lip, which then
no  longer finds in  this direction a convenient support;  that there
may, moreover, result from it so considerable a contraction of the
superior dental arcade, that it ultimately becomes incased in the infe-
rior dental arcade during mastication, an  example of which he cites ;
proposed  to preserve  the osseous projection, and  to limit himself
to pushing it backwards by applying upon the anterior surface of the
tubercle which it sustains a moderate degree of pressure during the
space of two or three weeks.   This method with him succeeded per-
fectly in  many instances.   Verdier and  other surgeons have since
obtained the same advantageous results  from it.  We should there-
fore adopt it  in cases of simple deviations of the teeth  the most approx-
imated to the median line.   To extract the projecting teeth after the
manner of Gerard, and as most modern operators recommend, is an
extreme remedy, which must not be decided upon until after having
fruitlessly endeavored to restore them to  their place, either by com-
pression or  by drawing them back towards the mouth by means of<
metallic wires fixed to the lateral teeth.   Finally, it rarely happens
that by means of precautions judiciously applied, and a little patience,
that we do not succeed, in young subjects  in causing these osseous
projections to disappear without destroying  anything.   If the teeth,
or the bone  which encloses them, do not  present in  front either irre-
gularities or angles too acute, the operation, nevertheless, may ulti-
mately succeed.  The  reunion having been once  effected, the pres-
sure of the lip upon these parts suffices to give to them again, at the
expiration of a greater or less period of time, their  proper direction
and position.  In certain cases there would be an advantage also  in
proceeding  after  the  manner of  M. Gensoul, in a  female in whom
the  intermaxillary projection, containing incisor teeth, had acquired  a
position almost horizontal, and after  the manner of M. Champion
(communicated by the author) in another case.   M. Gensoul, after
having dissected and reversed towards the nose the  flap of soft parts,
and  removed  the four incisors, seized the projecting  portion of the
bone with a strong pair of forceps, as if for the purpose of breaking
it off, and succeeded in this manner in giving it a perpendicular direc-
tion ; then  depressed,  in  the  same manner,  the right canine tooth •
afterwards excised  the four  borders of the double  harelip, inserted
the  twisted  suture  into it, and maintained the whole by means of  a
bandage.  This young patient, who was thirteen years of age, was per-
fectly cured.  The bone thus consolidated, as well as the canine tooth
in the new position  which had been given to it, and  its border, which
reached to  the line of the molar teeth,  became sufficiently  firm to
serve as a  point  d'appui  to the inferior incisors during  mastication.
M. Champion, who  dispensed with extracting the teeth, nevertheless
succeeded perfectly well.   In a newly born infant which I operated 
LIPS.
13
upon with M. Rivaille, in 1837, I found that the median point, which
sometimes  makes  an appendage to the lobule of the nose, had to be
elevated posteriorly, in order to reproduce the nasal subseptum, and
not depressed into the fissure of the lip.
  III.  The simple fissure, or that  in the form of a capital Y, in the
maxillary  vault, to remedy which the ancients  supposed nothing
could be done, and which moreover prevented them from attempting
to treat the harelip with which it is so often complicated, presents no
obstacle whatever to the success of the operation, and requires in this
respect, unless there  should  be too great a separation, no special
modification in the process.
  After the suture, the borders gradually approximate, and it some-
times,  of itself, ultimately disappears completely, as is proved by ex-
amples which are  already found in Roonhuysen, Sharp, De la Faye,
Levret, (Art. des Accouch., 3d edit., p. 252,) Quesnay, Richter, B. Bell,
and Lapeyronie.  In the instance noted by Gerard, this fissure, which
was not less than a finger's breadth in width, closed up at the expira-
tion of two years.  Some few weeks were sufficient to effect this in
a patient of Desault, and M. Roux mentions a  child three years of
age in whom  scarcely any traces  of a  similar  separation were ob-
servable at the expiration of the fifth month.   The moderate but reg-
ular and constant  pressure which  the lip, whose  continuity  has just
been re-established, exercises upon the whole external surface of the
bones, is the cause of this truly remarkable phenomenon.  Neverthe-
less, if it should be too tardy in being accomplished, either in conse-
quence of the long standing of the disease or because of the very con-
siderable chasm which the two maxillary bones leave between them, I
do  not see  why we might not endeavor  to favor it by means of com-
pressing bandages either below the cheek-bone and on the skin, after
the recommendation of Jourdain,  (Mai. de la Bouche, t.  II., p. 449,)
and of Levret, (Anc. Journ. de Med., t. LXXXIX., p. 543, 40, 772,)
though censured by Richter, but justified by Leblanc, (Precis d'Op-
erat., t. I.,  p. 25,) or directly upon  the  alveolo-dental  arcades  them-
selves, as  was  done by me in 1825, or by embracing almost the
entire  head with Dent's bandage, or the ribbon dressing of Terras.
There would be  moreover a  great number of modes of effecting this;
and the object being once clearly ascertained, each surgeon would be
enabled to devise the most suitable course to effect it. As in these dif-
ferent  cases the  lip has posteriorly but  a very unequal point  d'appui,
and that any extraneous plate kept behind its posterior surface would
have the serious inconvenience of irritating the  parts, the bandage
should be arranged in -such  manner that it would not exercise any
great degree of  pressure in front.  It  is unnecessary to add that the
needles cannot  be withdrawn with any. degree  of safety until the
fourth  or fifth day.
  IV.  The most proper age for the operation.—Another point still
remains to be examined.  Is it prudent to operate  for harelip in the
first months of infancy, or is it better to wait until the age of reason ?
This last opinion, advocated by Dionis and most of the  surgeons of
the 18th century, is almost exclusively  adopted at  the present day
among us.  The reason given for  it is, that  the young infant, incapa-
ble of  assisting in the precautions that such an operation requires, cries 
14
NEW ELEMENTS OF OPERATIVE  SURGERY.
 and becomes agitated and abandons himself to the most violent move-
 ments as soon as he is attacked.  The mere sight of the surgeon  or
 those who have approached him during the cheiloraphy, are sufficient
 to excite his terror and to throw him into a state of emotion.   The
 slight degree of consistence and the little resistance of the tissues to
 the knife, (secabilite,) occasion the points of sutures to be torn out upon
 the slightest degree of traction.  The tongue, hab tuated to the efforts
 of suction, constantly presents itself between the lips, and more  or
 less interferes with the reunion.   The  rigid diet which  is necessary
 for several  days sometimes produces,  says Lassus,  an emaciation  so
 rapid that, at the expiration of 24 or 48 hours, the cheeks of the infant
 become  flabby and  all  the  portions of the suture  greatly relaxed.
 Finally, it is a matter of very little consequence to the patient whether
 he is cured a little sooner or a little later, so long as he has not yet
 arrived at the period of talking.  After the third or fourth year, how-
 ever, the difficulty which he experiences in giving  utterence  to his
 thoughts, the railleries of his little comrades, and the consciousness of
 his own  infirmity, naturally create in his mind a desire to be relieved
 of it.  Then too, reasoning  or entreaty or menace, have already
 begun to have a certain influence over him.  He may then support
 the diet,  and the density of the tissues is much greater.
  To these arguments Busch, of Strasbourg, who with Roonhuysen,
 Sharp, Le Dran  and Heister, had adopted the opposite opinion, re-
plies, that we may prevent the cries and movements of the child by
interrupting his sleep for several days beforehand,  and  by adminis-
tering to him preparations of opium a short  time  before operating
upon him, in order that he may become calm, and  may sleep imme-
diately after ; that a child of three, six and even ten years of ao-e, is
often more difficult to restrain than if he was still at the breast;  that
the  latter, entirely unconscious of fear,  is affected only by real pain or
wants, whereas  the other recoils even at  the suggestion  of the
slightest  degree of suffering, and in reality attaches but very little
importance to the results of the operation which is  about to be per-
formed upon him; that if in the first case the tissues are more easily
divided  and lacerated, this is compensated by their  being better dis-
posed to favor the completion of the agglutination with  promptitude
and certainty.   I will add that when the suture is adjusted, the move-
 ments required for the introduction of a small quantity of milk or broth
 present  but  a very slight obstacle to the cure;  while up to that pe-
 riod the  harelip has  scarcely permitted the little patient to become
 accustomed  to sucking.  The prolonged duration of the disease in-
volves many more inconveniences than would seem to be imao-ined.
It interferes with the development of the intellectual faculties by the
impediment  which it occasions to the pronunciation, and therefore to
the employment  of the ordinary means for education.   When the
separation of  the vault  of  the palate is  complicated  with  it  the
longer we wait, the more  the bones become  separated  apart, in
consequence of the  want of resistance from without.   In  this  last
 case, sucking and even deglutition itself may be rendered extremely
difficult, and death  by inanition become  unavoidable;  examples of
which exist.   Moreover, in  opposition to the arguments of Lassus
 Sabatier, M. Roux, &c, we may oppose the daily practice of the Eno-. 
LIPS.
15
lish surgeons, the  successful result obtained  by Muys, Roonhuysen,
Le Dran, Bell, Busch and Bonfils, (Ephem.  Med. de Montpelier,  t.
VI.—Gaz. Med. de Paris, 1832,) on infants only some days or a few
weeks  or months old, and the three instances which  have been pub-
lished by M. Delmas, (Ibid.)   It is moreover  during the first months,
and as near as possible to the period of the birth of the infant, that I
would  operate, unless I should think proper to wait till the termination
of its first year of its infancy.  As soon as the second  year arrives, the
patient having become more intractable, does  not therefore  possess
more reason, and  the inconveniences  of  his position, which are no
longer of a nature to jeopardize his life, allow us  to temporize for three
or four years longer;  thus I  would choose the six first  months of in-
fancy, or from ten to fifteen years, as the proper time of operating for
harelip ; that is to say, I would rather recommend to those who have
not been operated on in the first period, that they should  wait for the
second.  If, however, the borders of the  division were separated so
wide apartas to render it almost impossible to bring them into contact,
it would be useless to attempt the suture.   I  have seen it under such
circumstances attempted without success in  1822, at the hospital of
St. Louis on an infant  about a month old ; but it is doubtful if it
would have succeeded better at a later period.   Why not commence
in serious cases by diminishing the intermaxillary fissure by means
of a good compressor, similar to the spring that M. Pointe, of Lyon,
(Journ. Univ. des  Scienc.  Med.,  Juillet, 1825,) in 1825,  and M.
Maunoir, of Geneva, (Clin, des Hop it., t. III., p. 48—Gaz. Med., 1.1.,
p. 229,) a little later found to answer so satisfactorily ?  Why not
separate the posterior surface of the two halves of lip from the bones
as far as to the neighborhood of the cheek, in order afterwards  to
bring  them together  with greater facility, in the manner as had
already been recommended  by Franco, J.  Fabricius, Horn, Nuck,
Roonhysen, &c. 1   In whatever manner the surgeon moreover pro-
ceeds, he should before taking the instrument in hand  duly reflect,
that notwithstanding  all its simplicity, the operation  for harelip re-
quires skill  and dexterity; that if he does not properly appreciate all
the different  stages of the operation, he  will necessarily perform  it
badly,  and  to the  same extent that it will  confer honor upon him
when  he  performs it in  the most skilful manner, to the same degree
will it be discreditable to him when he only  succeeds imperfectly.

                     § II.—Cancer of the Lips.
   All  kinds of cancerous tumors and degenerescences  are neither
more  nor less capable of being cured in the lips  than elsewhere.
The ablation, when it is practicable, is almost  the only  remedy.   It
is doubtful, except in a few slight cases, if  caustics, which  are still
employed successfully it is said by MM. Fleury, Patrix, (Emploie
de la  Pate Arsenicale,  1816, in 8vo,) Hellmond, (Bull, de Feruss.,
t. VI., No. 74 ; t. IX., No. 244,)  Haime, (Precis   Med. d'Indre  et
Loire] 3e trimestre, 1817,) Chelius, (Bull, de  Fer., t. XIV., p. 79,)
Magliari, (Ibid., t. XIX., p.  284,)  Heyfelder,  (Ibid., t. XII., p. 63,)
&c, can be substituted for it, even  though we should make use of the
zinc paste eulogized by M. Conquoin, (Bull, de  TherapeuL, t. VII., p.
243, 375,) or the Eau Regale or chloruret of  gold  made trial of by 
16
NEW ELEMENTS OF OPERATIVE SURGERY.
 M.  Recamier, (Ibid.,  t. VIII., p. 300.)   1  have shown in another
 article what course  is to be adopted when the maxillary bone itself
 is affected;  I do not  therefore intend, on the present occasion, to
 treat of any  other matter than what concerns the soft parts.  When
 the  disease occupies only a small extent of the labial border, or that
 it extends more  in a vertical than a transverse direction, the opera-
 tion, which is as simple as it is easy, may be performed in two ways.
   A. Excision in V.—The first consists in  circumscribing the can-
 cer  by two  oblique  incisions in a  triangular flap or sort of V, the
 base of which should correspond  to the free border of the lip.  The
 patient and  the assistant are arranged in the  same manner as for
 harelip.   The surgeon embraces the morbid  tubercle with the thumb
 and  forefinger of one  hand ; while with  a good pair of scissors or
 straight bistoury  in  the other, he forms his  flap, taking care  to cut
 into  the sound parts and from the buccal opening to the point of the
 V. which  he  proposes to excise.  The excision being now completed,
 nothing remains but to approximate the  borders of the wound  pro-
 duced  by it, to maintain it  united  by  means of the suture, and to
 treat it in the manner of harelip.   This method, the only one which
 has  been  for  a long time followed, is applicable  to the upper as  well
 as to the lower lip, to  its middle  portion as well as to the angles of
 the mouth, and ought to be preferred so long as it does not become
 necessary that there should be any considerable loss of substance, or
 that  we should destroy more than half, for  example, of one  of the
 lips.
  B. Semilunar excision.—The other  mode is  still more simple in
 appearance.   It resolves itself into a simple semilunar incision, which
 includes in its concavity all the diseased tissues, is  made with  the
 bistoury, or the scissors  curved flatwise, and leaves as its result only
 a notch of greater or less depth.  It is  adapted only to the lower lip
 and  when the disease  extends  less  in  a vertical than a  transverse
 direction.  Some  modern surgeons have erroneously  claimed the
 first  suggestion of this process.   It was in use at the time of Le Dran,
 and  Louis mentions  a  patient who  had been operated upon by this
 mode, and in whom it was  said the lip had  grown out again, (etait
 repoussee.)   Camper (Prix de VAcad,  de Chir.,t.lY.,r). 585,  1819)
 also  gave it  out  as  his invention.  We find it even  in Fabricius
 ab Aquapendente, who  remarks  very justly that we may in this man-
 ner remove a large portion of the lip, and that the deformity  which
 results from it is infinitely less than one  would be induced to suppose
 However  this may be, it  was almost entirely forgotten until M
 Richerand, A. Dubois, and Dupuytren revived  it into credit amoncr
 us.   Two circumstances combine, after excision  performed in  this
 manner, to favor  the elevation of the wound  towards  the dental
 arcade.  These are  the pressure outwards  upon the sound tissues
 produced  by the  development of cancer, and secondly the gradual
tractions which, at a  subsequent period, the cicatrix exercises upon
the integuments of the chin or even upon the upper part of the neck
 It has  been  seen,  in fact, that  the  surrounding soft parts, in per-
sons  who had in this manner lost the lip from one commissure  to the
other, and in the  whole extent of its breadth, became elevated  and
sufficiently convergent  towards  the mouth to reach as far as  to the 
LIPS.
11
 root of the teeth and even still higher.  In the most fortunate cases
 the mucous membrane of the arch of the gums becomes united to
 the corresponding  portion of the wound, and yielding to the cuta-
 neous tissue which tends to draw it outwardly is reversed forwards,
 as if in  order to furnish to the border of the new lip the vermilion
 pellicle which naturally belongs to it.
   C.  Hem.—This process however is not as good as the first; when
 using this  the cure is always  less prompt  and the deformity always
 more  perceptible.  Consequently it should be reserved for excep-
 tional cases.   An  improvement  which  might be made in it, and
 which M.  Serre  has  already  employed in  practice, would consist in
 immediately uniting the mucous border with the cutaneous border of
 the wound, or as I have successfully done, bring it down in form of
 a hem by means of the simple or  whip suture.   We should in this
 manner procure  in three days, a cicatrix more pliant and neat than
 that which we could get from the ancient mode in a month.
   D. Under the  most unfortunate  circumstances, a  greater or less
 extent of the jaw remains exposed after  a  removal of cancer of the
 lip.   Speech  then becomes imperfect, and  the  patient constantly
 losing his  saliva, is placed  under the necessity of wearing a metal-
 lic apparatus to the chin furnished with a sponge.   Fortunately how-
 ever  at  the present day, we  are in  possession of other modes of
 avoiding this inconvenience. (See Cheiloplasty.)  It is important how-
 ever, to remove in good season and freely, cancerous tumors of the
 lips ;  otherwise they repullulate in  the neighborhood and below the
 jaw with  frightful rapidity.  A  peasant of a robust appearance, in
 whom I removed one which did  not exceed in size a small nut, died
 at the expiration of eight days with hundreds of cerebriform granules
 in the liver!

       §  III.—Eversion (Reversion) and Mucous Bourrelet.

  The lumps,  and especially the species of red-colored ridge which
 many persons  have on the internal surface of the free  border of the
 lips, is a deformity which  has  been hitherto paid very little attention
 to in  surgery.   They  are  sometimes seen in the upper lip, which
 is most predisposed to them, sometimes upon the lower lip, and oc-
 casionally  in both lips at once.  In certain  cases, under the form
 of one or many tubercles that are  scarcely perceptible, at other times
 under  the  aspect of a transverse projection, which strongly pushes
 the lip towards the skin as  soon  as  the patient attempts  to laugh or
 speak.   Though it is usually a congenital defect, it sometimes occurs
 accidentally, especially in  persons who play the horn or are obliged
 to cry  with great force.  Their presence has nothing dangerous and
 involves  no other inconvenience  than that of rendering the  counte-
 nance  somewhat less agreeable.   Also, most of those who are  af-
 fected with them, have them all their lives  without ever thinking of
getting rid  of them.  Nevertheless in certain classes of persons they
become embarrassing, as in hunters,  musicians and orators for exam-
ple.  Instances of this  kind are  seen  in the two patients who were
operated  on in 1829, by M. Roux and  Boyer.   They are, however,
 cured with great  facility.   They are to be excised either with the
  vol. in.                      3 
18
NEW ELEMENTS OF OPERATIVE SURGERY.
scissors curved on the flat side or with the ordinary bistoury. While
an assistant stretches the lip at its two angles, and exposes its inner
surface to view, the surgeon seizes hold of as much of the vegetation
as possible by means of a good  pair of forceps placed transversely,
raises  it up a little, and afterwards proceeds as in the excision of the
bourrelet of the conjunctiva in ectropion.  Numerous cases from diffe-
rent authors, or those mentioned in the lessons of Dupuy tren, show that
at the end of a week or two the cure is complete, and that the deform-
ity which has been thus treated, has entirely disappeared.  Neverthe-
less, as there are in this part under the elongated tissues numerous hy-
pertrophied mucous glands, which glands  and follicles it is necessary
to remove, and as I have seen the wound in certain persons take on a
bad aspect, and require nearly three weeks or a month to cicatrize, I
have adopted another method.   Having seized the mucous  fold  with
a pair of forceps, I pass through its  root or base near the  muscular
tissue, three or four threads which I leave  there.  I then immediately
excise  the  bourrelet near these  threads, after  which I have nothing
more to do than  to knot the  points of the suture, which may be re-
moved on the second or third day.   The same operation would be
equally applicable without doubt, to the eversion of the lips produced
from any other  cause, as  for example, by bridles  or  ancient cica-
trices, so true  it  is that this condition of the mouth has the greatest
degree of analogy to ectropion  or eversion of the eyelids, and that
it is susceptible of the same surgical remedies.

                §  IV.—Hypertrophy of the Lips.

  The thickening of the upper lip, which may be considered almost a
natural  result  in scrofulous  subjects, may exist  to such extent as
to constitute a serious  disease if not a disagreeable deformity.   In
certain  cases the  totality  of the  lip acquires  so  great a degree of
development that its posterior surface ultimately becomes  reversed
downwards and  its free border directly forwards.   So  long as there
is a morbid action  going  on and that the  hypertrophy is  not posi-
tively established and not reduced to the condition of a simple defect
of conformation, we should confine ourselves to internal or external
treatment and to the proper general or topical  remedies.  But when
all the resources indicated by a  sound therapeutic  have been  em-
ployed in vain, and that the affection has  become purely  local, there
is no other than  the cutting instrument which can destroy  it, unless
we should  be  disposed to make  trial of  compression and  caustics.
The operation which is proposed for the relief of the patient was sug-
gested, in 1826,  by M. Paillard,  (Journ. de Progres, t. III., p. 213^)
who performed  it in three instances with  entire success, and  who
gives three other examples of a fortunate issue obtained in  the same
manner, by MM. Marjolin  and Belmas.  It consists in un-doublinij the
lip and reducing it to its normal dimensions by excising a layer
from its tissue of greater or less  degree of thickness.  The assistant
charged with supporting and holding the head of the  patient back
against his chest, is  also made to  stretch the part and cause it  to pro-
ject  outwards by seizing it at the left commissure with the forefinger
and thumb of the corresponding hand.  The operator placed in fron 
LIPS.
19
 and a  little to the right seizes  hold of the other commissure, then
 with a  bistoury in his right hand makes, from one labial angle to the
 other, and perpendicularly on the border of the diseased lip itself, an
 incision which is slightly somewhat more approximated to the mucous
 membrane at its extremities  than at its middle; in this manner cir-
 cumscribes every thing  which it is  his intention to remove; imme-
 diately embraces  this flap with the forceps and dissects it rapidly
 with the same bistoury from the free to the adherent border, and
 from the left to the right extremity of the part, down  to a level with
 the sound tissues; endeavors to give it all the breadth and thickness
 required, while taking care to approximate it gradually to the mucous
 coat before terminating the  excision near the  alveolo-labial groove
 with the last  cut of the bistoury or a good  pair of  scissors.  The
 wound which  results from it sometimes bleeds copiously, though in
 general it yields  with  facility.   No kind of  dressing is  necessary,
 inasmuch as the traumatic surface, from being continually lubricated
 by the saliva, becomes rapidly cleansed.  In cicatrizing it reacts upon
 the  integuments, gradually  brings them  forward, or even tends to
 incline  them downwards, and in cases  of complete cure,  the lip not
 only returns to its natural thickness, but also to its normal direction.

                     §  V.— Various Tumors.

   M. D. Lasserve, by excising in this manner from the upper lip, was
 enabled to remove an enormous  fibrous tumor.   A boy aged fifteen
 years was brought to me from Vaugirard by his father, in 1836, to
 the hospital of La Charite, for an elephantine tumor, which  he had
 had  upon his upper lip for   the space of three years.  This tumor,
 which was badly defined, half the size of an egg and  indolent, occu-
 pied the entire thickness of the lip and did not, after having been re-
 moved  by the V excision, return again in the manner of cancerous
 tumors.  Sebaceous and mucous cysts, those that are serous, and all the
 descriptions of tumors which  I have elsewhere described, are quite fre-
 quently met with on the lip.   An erectile tumor was extirpated from
 this part with entire success by M. PI. Portal, (Clin.  Chir. &c, pp.
 139, 144.)   Under  the chapter on erectile tumors I have described
 the  number of processes that have  been adopted for those of the
 lips.   M. PI. Portal also states that he successfully extirpated one that
 was  situated upon the  chin.

   § VI.—Atresia and  Contraction  of the Anterior Opening of the
                             Mouth.

   Boyer, who says that he never saw an instance of imperforation of
the mouth, was doubtless unaware of the fact, that Haller had men-
tioned  several  instances in the  human species and in animals ; that
Monro had noticed this imperforation in young pigs, and that Verdier
(Abrege d'Anat., t. II., p. 124,) states he had seen an instance in a dog.
This last author also relates, on the authority of Gregoire, an instance
of a  newly born infant who had neither mouth nor nostrils, though it
was  born alive.  Schenckius, (Planque, Bibl. de Med., t.  I., p. 305,
in 12, art. Accouch.,) had already mentioned that he  had met with 
  20           NEW ELEMENTS OF  OPERATIVE SURGERY.

  infants in whom he was  obliged to lay open  the  mouth, and Des-
  genettes  (Gaz. Salut., 1792, p. 95,) states that  he had seen*a seven
  months' foetus in  which the  mouth was  imperforate.  It is shewn,
  therefore, by these facts, that imperforation of the mouth may be
  congenital.  Other observations prove that it  may also  take place
  after birth. G. Horstius (Turner, Mai. de la Peau., t. L, p. 120,) relates
  that  in a miller, the lips, after having been excoriated, became glued
  together.  A small hole which had  previously allowed of the intro-
  duction of aliment into the mouth, by means of a  funnel, itself ulti-
  mately closed up, so that the poor patient starved to death.  Though
  the entire obliteration  of the mouth  may  be infrequent, it is not so
  with  simple contraction, or coarctation of the lips.   This contraction,
  which, like imperforation, may be either acquired or congenital, may
  result, moreover, from various descriptions  of diseases.  A newly
  born  infant mentioned by Demarque, (Op. cit.,pp. 449, 450,) had the
  opening of the mouth so small that it was scarcely  possible to intro-
  duce  a pea  into  it.   Another  individual mentioned  by the same
  practitioner, had the mouth contracted to the  extent of a finger's
  breadth  on each side, in consequence of small pox.   Demarque
  (Traite des Bandages, p. 447,) mentions also a woman  and child  in
 whom the opening of the mouth was in this manner almost entirely
 closed, in consequence  of burns.  When the imperforation is com-
 plete,  as in the patient of Buchner,  (Planque, Bibl. de Mid., t. XVI.,
 p. 166,) or in that of Percy, (Memoire  sur les Ciseaux, § 5, p. 70,)'
 we  must  in  the first  place incise  in  the direction of the  natural
 opening, and upon the part of the cicatrix  which appears  to be the
 thinnest.   As soon as  the bistoury has  passed  into the mouth  it is
 well to replace it by the scissors, one  of the blades of which is to be
 inserted through the  small  opening which has  just  been made
 Percy succeeded  in this manner in the young Count D'Amblv   The
 operation was also followed with entire success in the  child mentioned
 by Buchner.  In  those cases, on the contrary, where  an aperture still
 remains, the operation is  manifestly more  easy, since it  is always
 then practicable to  follow with the eye as far as into the mouth  tL
 instruments that  we make use of.   I will not  recur again to' th*
 methods which present the best chances of success in  such cases and
 which  I have described in the chapter on anaplasty.  I will refer
 only in proof of the difficulty of curing coarctation, or imperforation
 of the  lips by simple incisions, to the  history of the miller of Horstius
 The hps of this patient, m  fact, after  having been separated by the'
 instrument, obstinately reunited  a first, second, and even a thiJ^•
 We  also  find  in  a case of M. Bondi,  (Bull deFeT,l II ifS\
 that the incision made  in order to destroy a coarctation of th ' V
 did not prevent the infirmity from being re-established to so JL  t
 degree in  fact, that the opening  of the mouth was  reduced tVTti a
 diameter of a pin's head, and that death succeeded at the term"   t
of a few days, during a paroxysm of asthma.  It is,  howeveTt^r
remarked, that  in the patients mentioned by Demarque this
tion appears to have fully succeeded,  and  to have been'unattST^
even with any difficulty.   (See  Cheiloplasty.)            unattended 
LIPS.
21
          § "VII.—Too Large an Opening of the Mouth.
  In the Germanic Ephemerides, (Bull, de Feruss., t. II., p. 69,)  we
find the history of a child in whom the mouth extended as far [nearly]
as  the ears.  Having operated upon one side, an interval of some
weeks was left before doing the same for the other, in consequence
of the first operation  having produced an alarming hemorrhage.   I
do not know to what extent it  is possible for the mouth to reach
up  to the  ears.   I  have,  however, myself  seen an old man  in
whom the mouth had been enlarged as far as the anterior border of
the masseter  muscles.  This  man  had entered the hospital  of La
Charite for a double cancer, which obliged me to remove almost the
entire length of the free border and the whole of the commissures of
the lips as far as to the cheek-bone.   The union of the parts had been
effected  by means of numerous points of twisted suture.  But  in
consequence of an erysipelas, accompanied with intense delirium,
which supervened on the third day, the patient, in separating his jaws
with  force, speedily  destroyed and tore  out  the  suture, together
with the first agglutinations, which had already begun to take place.
As  the general  affection continued nearly fifteen days, the lips of
each wound cicatrized separately.  In consequence  of which  there
resulted  a hideous deformity, which prevented  the  unfortunate old
man from entirely closing his mouth, or  from being enabled to retain
his  saliva effectually, or  from performing mastication in a proper
manner.  It might have been practicable or even easy, by abrading
the borders of these enormous prolongations of the  mouth, to unite
them  by suture, and  in this manner destroy the deformity; but  the
patient, satisfied with the cure of  his  cancer, and weary of  his
sojourn in the hospital, was desirous of returning  home, and posi-
tively refused every proposition for another operation.  As to the
remark, that the mouth is either too large  or  too small when  there
are no traces  of cicatrix or  degenerescence upon the  free border of
the  lips, this can scarcely be conceived  to be  possible, inasmuch as
the  natural dimensions of this opening have not and cannot have any
thing  absolute about them; unless we should admit with G. D. Tho-
losin,  (Gaz. Salut., 1766,) "that the  mouth (in every person) should
be limited to the exact length of the first bone of the thumb."  Opera-
tions,  therefore, cannot be required except for extraordinary cases of
narrowness or enlargement,  which are produced by certain diseases.

   § VIII.—False Anchylosis.—Stiffness in the movements of the
                           lower jaw.

  Temporo-maxillary arthropathy, like all those diseases which may
be developed around or in the neighborhood of the condyles of the
jaw, are capable of producing there an  induration or stiffness to so
great  an extent, that the separation of the dental arcades will be
thereby more or less impeded.  Certain chronic inflammations of the
windpipe, internal phlegmasias at the bottom of the mouth, those espe-
cially which take place in the neighborhood of the last molar tooth, may
also sometimes give rise to the same infirmity.  The patient in such
cases  cannot open his mouth.  Various methods of cure are then re-
sorted to. 
22
NEW ELEMENTS  OF OPERATIVE SURGERY.
   A. M. Ghidella,  and some other practitioners,  who assert  that
 they have succeeded bv making numerous incisions  upon  all the
 indurated ligamentous or cellular  plates, could only  have encoun-
 tered those anchyloses, which are produced  by retraction of the
 fibrous  tissues.  In my own  opinion,  it would not be prudent to
 recur  to this  process,  unless  the  fibro-muscular bridles  should
 be distinctly perceptible through the integuments.  Tenon, (Mem,
 sur  VAnat. et  la Chir., t. II., p.  261—262,)  who  saw a case of
 this  kind, resulting  from a deep-seated disease of the jaw, and af-
 terwards another, which admitted only of a separation of some lines
 in extent, had recourse to the employment of wedges of cork.  The
 defect of conformation was congenital; after having divided one of
 the labial commissures, it was found that  a  cicatrix  formed and re-
 duced the opening of the jaws to two lines.  Tenon insinuated be-
 tween  the teeth two wedges  of cork, the thickness or number of
 which were gradually increased, until the mouth could be opened to
 the extent of nine lines in place of  two.
   B. Dilating wedge.—This idea, of placing a wedge  between the
 dental arcades, has been improved upon by M.  Toirac, (Mem. sur la
 derniere Dent Molaire, p. 13,1828,) who has obtained really successful
 results from it in different patients whom I have seen, and who had
 been, during many months, unable to separate  their  teeth beyond a
 few lines.  The remedy moreover is simple and of easy application.
 We begin by a  thin and very elongated  wedge, which is to be in-
 serted between the two dental arcades, nearly as far as to the coronoid
 process ; the size of this wedge is to be daily increased, until  the
 movements of the mouth have  regained their extent and liberty.   It
 is obvious, however, that the presence of a cork or wooden wedge
 between  the dental arcades can  scarcely present any hope of suc-
 cess  except  in  cases  of immobility unaccompanied  with unnatural
 adhesions of the gums with the inner surface of the cheeks or with
 actual anchylosis of the articulation.
  C. The wedge and incisions.—M. Mott having met with many ob-
 stinate and complicated cases, has devised an instrument, which acts
 at once in the manner of a wedge, lever, and saw.   This instrument
 which might, if necessary, be made to divide the coronoid process or
 the root of the neck of the condyle of the jaw,  possesses the power,
 as a wedge and a lever, of gradually widening, and with a great
 degree of force, the  two maxillary bones.  The surgeon  whom I
 have just cited, and  who  performed this operation  successfully on
 seven different patients out of the eight that came under his treat-
 ment, was obliged  in some cases  to divide the commissure of  the
 lips largely in the manner of T6non, and to leave each border of  the
 wound to cicatrize  separately,  not reuniting them until after having
 completely re-established the  movement of the jaws.  This is an
 operation, however, which, notwithstanding what has been said of it
 on the authority of M. Mighels (Gaz. Med., 1834, No. 26,) and of M
 Mott, (Journ. de Progres, t. XIII., p. 925,) and what the author has
recently  written to me concerning  it, is still too imperfectly under-
stood among us to enable me to affix to it its just value.  [See chanter
on this subject by V. Mott, infra.  T.]                       y er 
CHEEKS.
23
             § IX.—Unnatural adhesion of the Cheeks.

   It frequently happens in consequence of mercurial, carbunculous,
 or other inflammations, and as the result of any other kind of ulcer
 which may occur in the mouth, that the inner surface of the cheeks
 becomes agglutinated to the outer surface of the jaws or gums.  From
 whence happens  a deformity analagous to that I have just described,
 that is to say, an impediment to the separation of the jaws and the
 movements of the mouth.   These adhesions  sometimes make such
 effectual resistance to the movement of the jaw, that it is impossible
 for patients to open their mouth.  Numerous examples of this are re-
 lated in scientific works, and I have myself met with some of them.
 In appearance nothing is so easy as to remedy this disease; in re-
 ality nothing, however, is more difficult.
   A. Decollement.—The first idea which suggests itself is to attack
 and destroy, either  with  the  scissors or bistoury, the  bridles  and
 cellular attachments which constitute the  abnormal  adhesion,  and
 without interfering with the continuity of the  tissue  proper of the
 cheek.  But in reflecting on this point we soon  perceive that  this
 dissection,  which as an operative process presents no difficulty, and
 in fact momentarily destroys the deformity, can only effect a radical
 cure  in exceptional cases.  What prevents the outer  side of the
 gums and inner surface of the cheeks from agglutinating together in
 the natural state, is  the  existence of the mucous membrane which
 lines both of them.   Now this mucous membrane, which has disap-
 peared  in the cases of adhesion, cannot be reproduced by the dissec-
 tion which I have just mentioned.  It must result, therefore, that the
 incisions which have been made will, in cicatrizing, reproduce the de-
 formity. In even admitting that the entire traumatic surface may have
 cicatrized upon the cheek, independently of the gums, it could only do
 so at least by the production of an modular callous and inextensible
 tissue, which in  itself would be calculated to interfere  excessively
 with the separation of the jaws.   This difficulty  is  met with in all
 the other modes of operation which have been proposed as a remedy
 for the closure of the jaws.  It is important therefore that we should
 not deceive ourselves on  the subject  of the apparent simplicity of
 this deformity, any more  than we should  upon the efficacy of the
 means which we may have it in our power to oppose to it.
   B. However this may be, there are many processes to be  made
 trial of in   such  cases.   The most  simple  is  that  which I have
 attributed to M. Toirac in the preceding paragraph, and which con-
sists in forcibly separating the jaws by means of wedges successively
augmented in size, and introduced to a great depth into  the most
remote  part of the dental  arcades.  This means,  when there is no
rigidity  in the tissues or when the adhesions are  recent and of but
little extent, will suffice if continued  for the space of fifteen days or
a month, giving a respite  of some hours to the patient from time to
time, and resumed afterwards from week to week.
  C. The process of M. Mott, that is to say, the introduction  of a
wedge performing the office of a saw and  lever, in such manner as
to allow of the division  of the bone if necessary, would become
 requisite should the jaw be anchylosed or surrounded with modular 
24
NEW ELEMENTS OF OPERATIVE SURGERY.
tissue endowed with a great degree of resistance.  The instrument
of the surgeon of New York would also have its advantages as an
auxiliary means, when it becomes indispensable to destroy the ^ff-
nal adhesions of the cheek or lip, with the cutting instrument.   Inis
last method comprises three principal processes.
  D.  Simple dissection of the adhesions.—The most rational method
apparently, would  consist  in destroying by means of a straight or
blunt-pointed bistoury, glided upon the finger or a canulated sound,
or even without a director, from  above downwards between the
cheek and lower jaw, and then from below upwards between the
cheek and upper jaw, all the  abnormal adhesions  to a  sufficient
extent, and  in such manner as  not  to arrest the knife until  after
having reached as far as the pliant and perfectly sound tissues of this
region.  In this manner the operation is easy and prompt, and the
immediate result of it as satisfactory as possible.   The patient  is to
be seated  upon a chair.   The operator, separating one of  the  com-
missures with the forefinger and thumb of one hand or a good forceps,
directs his bistoury with  the other between the two  dental arcades
as far as to the neighborhood of the coronoid process.   Turning then
the edge of his instrument towards the outer surface of the teeth, he
divides with free strokes and in a direction parallel to the plane of
each jaw,  all the bridles and unnatural tissues which attach them to
the cheek.  Should the teeth be so approximated as  to prevent the
instrument from gliding between them, he  should make  use  of a
canulated  sound in order to conduct it outside of  and  along the
alveolo-zygomatic (alveolo-jugale) groove.   It would  even, if neces-
sary, be practicable to plunge it into the tissues  from before back-
wards, if there should  be no groove  to admit of a free passage to
the director.   Having reached  this point we  have now to  struggle
against the tendency of the wound to reagglutinate.   To attain the
object in these cases we have need of two kinds of resources ; in the
first place we must procure, by means of wedges or levers, a suf-
ficient separation of the  jaws,  and it is for  this purpose  that the
wedges and levers of MM. Toirac and Mott are indicated.   If in
fact we did not commence by giving  a great degree  of freedom to
the movements of the lower jaw, new adhesions and an almost insur-
mountable contraction of the tissues would  not  fail  to take place.
On the other hand, we cannot prevent the inner  side  of cheek, now
transformed into a  traumatic surface, from becoming reunited to the
outer side  of the gums, except by keeping some foreign body between
them.  Tenon, in  the three cases which I have quoted from  him
and which relate rather to the adhesions under consideration than to
a false anchylosis, appears to have succeeded by means of  pieces of
cork fastened by the aid of catgut against the outer side of the teeth.
It is to be confessed, however, that we rarely succeed  in this manner!
  A young girl aged sixteen years, who, in consequence of a car-
bunculous (charbonneuse) affection of the mouth, had had from her
birth a complete adhesion of the cheek and the right half of the lips
to the dental arcades, and who was admitted into the  Hospital of La
Charite in the month of January, 1836, had already undergone two
operations of this kind without any benefit.   I in my  turn destroyed
all the abnormal adhesions, and  I succeeded in procuring a separa- 
CHEEKS.
25
tion  of fifteen lines between the jaws in the space of a week.   A
piece of sheet  lead, protected by cork, and kept permanently be-
tween the teeth and the cheek,  appeared to me calculated to pre-
vent  any new  adhesion.  After the cure,  however, there resulted
only a slight amelioration, and a separation of only from three to four
lines.  It is necessary however to add, that the young girl evinced
an extremely intractable disposition, and that  in consequence of a
confluent small-pox, with which she was attacked  at the expiration
of a  month, I was compelled to remove every portion of the dressing
or foreign bodies from the interior of the mouth before the perfect
cicatrization  of the wounds.  A  young man who had similar adhe-
sions, which M. Serre had previously destroyed by a crucial incision
in the cheek, and which I treated in the same  manner in  1837, was
not less unfortunate.  After having  carefully dissected and isolated
the inner surface of the cheek throughout its whole extent, and after
having sufficiently widened  the jaws by means of levers and wedges,
I inserted in  his mouth a broad piece of sheet lead, upon which I in-
tended that the wounds  should cicatrize uniformly in every part of
them.  Every thing at  first went on as well as I could wish, and at
the  expiration  of five weeks, I considered my patient cured.   The
dispensing however with the use of the plate of lead during the space
of two days, caused the separation of the jaws to be diminished one
half, and nothing afterwards could prevent the inodular tissue from
reproducing  the deformity to as great a degree nearly as before.
   E. Like M.  Mott, I also was desirous in one case to ascertain if I
could succeed  better by laying open the whole cheek from the com-
missure as far  as to the  masseter muscle, and afterwards  dissecting
  ach of the borders of the incision, and leaving  them to cicatrize
  parately in such manner as to reunite them at a later period, as we
do in harelip.  The cheek being thus separated, no longer interferes
with the movements of the jaw, which can afterwards  be relaxed
and  widened by the proper mechanical means.   Having once  ob-
tained all that we desire in this respect, we reunite the borders of the
artificial division.   As  the  internal  surface of each of the flaps  has
had time to cicatrize, we need have  no  farther apprehension that it
will  reagglutinate  to the outer  side of the gums.   This  method,
which  had failed  in  one of the patients of Tenon, and which suc-
ceeded no better with me, nevertheless  procured some successful  re-
sults with M.  Mott.  It would  therefore be a process to be made
trial of as well as that of simple decollements, which, united with
cauterizations  by nitrate of silver, obtained a remarkable cure in the
hands of M. Gensoul, (Journ. des Hop. de Lyon, t. I., p. 494.) I be-
lieve moreover, that by means of determination on the part of the sur-
geon, and docility on the part of the patient, we could very frequent-
ly obtain cures by both these processes; but I repeat that success
here is infinitely less difficult to be accomplished than would at first
view be imagined.   We should be wrong moreover not to anticipate
a swelling and sufficiently marked inflammation of the cheek and a
large portion of the  face, when, after  such separations,  we decide
upon placing any foreign body between the cheek and the teeth with
the  view of preventing all reagglutination.   Perhaps it would be
better, should there be any inodular productions implicating the skin,
   vol. in.                      4 
26
NEW ELEMENTS OF OPERATIVE SURGERY.
to remove them, and immediately repair the loss of substance by means
of genoplasty, in taking a large flap in the neighborhood, as was done
successfully by M. Mott.  (American Journal of Medical Sciences,
Nov. 183L)
                Article V.—Salivary  Fistulas.

   There is no end to the remedies that  have  been devised for the
cure of salivary fistulas, and most of them, we must admit,  have
been attended with some success.

               §  I.—Fistulas of the Parotid Gland.

   A.  Cauterization, either with a hot iron or by means of chemical
substances, as employed by Galen, on a patient in whom the fistula,
the result of a  critical inflammation of the parotid glands (suite de
parotides  critiques), was situated under  the ear; and as employed
by Pare, the two  Fabricii, Heuermann,  Boyer, Langenbeck and a
multitude of others, succeeds very well  for fistulas  of the parotid
itself, that is to  say, those  which derive  their origin  from some
branches and not from the principal trunk of the excretory ducts of
the saliva.   Galen  had recourse to  catheretic plasters (emplatres
catheretiques), Pare to aqua fortis, Diemerbroeck and Jourdain to the
actual cautery, M. Higginbottom (Bull, de Fer., t. XXVI., p. 95), to
sulphuric acid, and  Boyer to nitrate  of silver.  The lapis infernalis
deserves the preference, because it produces a drier eschar and one
which is more adherent than any other.   Nevertheless if the ulcera-
tion should be narrow and very deep, a cautery of the red oxide of
lead might be substituted for the  nitrate of silver, as was practised by
me with success, in November, 1831, at La Pitie, in a man who had a
parotid fistula produced by the opening of an abscess behind the bor-
der of the jaw.
  B. Blisters. Styptics and astringents, which were equally eulogized
by some practitioners, Becket  among others, being less  efficacious
than caustics, have been long since abandoned.  I have cured two
patients, who had been affected  several months with parotid fistulas
by means of repeated temporary blisterings upon the diseased parts.
   C. Compression,  made trial of successfully by Beaupre, Le Dran
and Ruffin, who invented a machine for this purpose, advocated also
by Imbert, Jourdain and Richter, almost always answers the purpose
when the patient  can support it, and when the state of the parts per-
mit its employment.   For that  purpose we apply lint or graduated
compresses upon the fistulous  orifice,  after which, by means of a
fronde or chevestre  bandage, or by means of  turns of the ordinary
bandage properly arranged, we produce pressure on this  point in
such manner as to keep the walls of the diseased duct in contact.
   D.  Irritating  injections, as  proposed by Louis, have for their
object to inflame  the fistulous passage and to  bring  about its agglu-
tination.   They may be made with sweetened barley-water, decoc-
tion of French roses in red wine, alcohol  itself or any other exciting
liquid, according as the tissues, whose adhesive inflammation we  wish
to produce,  are  more or less  irritable.  It is a  remedy however
which comes only in the third class, because it exposes to more  acci- 
SALIVARY fistulas.
21
dents and is  not always successful, but one which, in some cases of
obstinate fistula, is not to be despised.
  E.  If none of all  these succeed, we  may make trial of excision,
comprising the ulcer in an elliptical wound, and afterwards reuniting
by means of  adhesive plasters or the twisted suture.  If the disease
still resist, we have no other recourse than extirpation of the gland ;
but this remedy, ascribed to Pouteau, by M. Hedelhofer, has  never,
I believe, been carried into execution.  It would be, in fact, a case in
which the remedy is  worse than the disease ; so much the more so as
these fistulas  sometimes finally disappear spontaneously, examples of
which are given by Nuck, Ferrand, A. Dubois and M. Richerand.

                § II.—Fistulas of Stenonfs Duct.

  These different modes of treatment, though less efficacious when
applied to fistulas of  Stenon's duct, have nevertheless, in some cases,
effected unquestionable  cures.
  A.  Cauterization, for example, alone or associated with compres-
sion, obtained for Louis an unexpected cure, in a patient  in whom
the fistula had existed for the space of nineteen years, and who had
already been operated on several  times without any benefit.  Mun-
nicks, (Praxeos Chirurg., lib. II.,) Lentilius, Lange, (Bibl.  Chir. du
Nord, p.  135,)  and Mosque, (Ancien Journ. de Med., t. LXXL,  p.
506,) have or had also succeeded in the same way.  Ferrand, Ne-
del, Mursinna, Imbert, Jourdain and M. Langenbeck have been no less
fortunate.  But M. Gendron (Annates de Cercle Med. de Paris,  t. L,
pp. 55, 92) has  since maintained that in all the cases of this descrip-
tion the fistulas were in the gland and not in the salivary duct.
  B.  Compression without caustic and as an exclusive remedy, has
also appeared to have been efficacious.  Maisonneuve, who was the
first to recommend it in such cases, established it between the fistula
and  the gland, with  the rational object of closing up the passage to
the saliva and enabling the wound to cicatrize.  His patient, who had
received a sabre cut  upon the  cheek, was  radically cured at the ex-
piration of 20 days.  Louis, and  with him most of the moderns, have
considered that by acting in this way, we almost necessarily produce
inflammation of the parotid, and that consequently this process cannot
but be dangerous.  Desault hoped to dissipate all these apprehensions
by directing the compression upon the gland itself, which he proposed
to atrophize.  Whether the atrophy had really taken place as Desault
asserts,  (Gavard,  Splanchnol, p. 208,) or that the parotid continued
to perform its functions afterwards, as Boyer  seems to think,  cer-
tain it is that the fistula  speedily  cicatrized and  that  the patient suf-
fered no return of it.  However this may be, there is in the treat-
ment of these authors, two distinctions which it is important not to
confound;  that of Maisonneuve, who proposes only to interrupt the
course of the  saliva temporarily, and that of Desault, (Vedrine, Journ.
de Desault, t. IV., p. 294,) who  prefers to dry it up at its source.
Without agreeing with Heuermann, that the parotid, under such cir-
cumstances, will always suppurate and ulcerate,  and pass into the
state of scirrhus or cancer, I can nevertheless not admit the innocu-
ousness of a remedy like this, which should in my opinion be reserved 
28
NEW ELEMENTS OF OPERATIVE  SURGERY.
 for  patients who have a  dread of every other kind of operation
 or have not been cured by them.  Trecourt (M6m. de Chir., p. 75,
 1769,) had recourse to it by applying it upon the ulcer-like Courtavoz
 because the seton was not  admissible.
   C. Ligature upon the duct.—Zang, who shares in part the opinion
 of Maisonneuve  and Desault, resorts  to  the process of Viborg, to
 atrophize the parotid.  In place of compression, which is always un-
 certain, this surgeon, inasmuch as the object is to prevent the  saliva
 from passing, proposes to apply a ligature on the duct  of Stenon
 outside of the fistula.   Quite a number of experiments upon animals
 towards the close of the last  century, demonstrated to him  that this
 ligature is unattended with danger.   In order to apply it, it would be
 necessary to make a vertical incision upon the anterior border of the
 masseter, immediately below the zygomatic arch.  The canal  being
 once laid bare, is to be isolated from the other tissues, especially from
 the branch of the facial nerve which accompanies it on its upper side.
 Nothing afterwards is easier than to surround it with a ligature, and
 obliterate it.   There is no doubt in principle that if the sacrifice of the
 functions of the parotid gland has been  decided  upon,  the advice of
 Viborg should be followed to the exclusion of  that of Desault and
 Flajani, if it could be proved that the saliva would allow the ligature
 to effectually obliterate the duct in this manner; but compression,
 presenting moreover the advantage of requiring no incision, will not-
 withstanding be adopted in  preference, by timid and pusillanimous
 patients:  whence it follows that these two methods  might each be-
 come susceptible in  practice of particular application.
  D. The twisted suture, as in harelip, when the anterior portion of
 the canal remains unaffected, answers, according to Flajani, Percy
 and  Zang, in many  persons, and in most cases renders  any other
 means unnecessary should it be applied in  good  season.  M. D. Las-
 serve (Cas. de Chir., p. 27, Perigueux, 1830)  having wounded  the
 canal of Stenon  while extirpating  an osteo-fibrous  tumor of  the
 cheek, made at the  bottom of the wound  an  opening of two lines
 which penetrated into the mouth, and the lips of which he successfully
 united by suture.  M. PI.  Portal  (Cli%. Chir.)  having extirpated a
 salivary tumor, was no less successful  in  another case.  The same
 occurred to M. Begin,  (Pathol. Chir., t. I., p.  209, 2d edit.)
  E. Seton through the natural duct.—Morand first, and Louis after-
 wards, are the two authors  to whom we are indebted for the idea of
 dilating Stenon's duct for the cure of its fistulas.   The surgeon being
 placed in  front of the patient, seizes  the labial angle by means of the
 thumb introduced into the mouth, and the two first fingers of the left
 hand applied upon the cheek if the fistula  is  on  the right side, and
with the two fingers of the right  hand, if it is situated on the left •
stretches*it and reverses to the outside ; introduces with the other hand
the head of a fine probe,  furnished with a thread, into  the  natural
orifice of the parotid duct;  withdraws it through the wound, where
he leaves the little seton whose two extremities he unites by a knot, and
by which  he is enabled on the day after to draw into the mouth from
the exterior to the interior a small cord of silk; and each day renews
this meche by withdrawing it through the wound and by adding to it
each time one strand more.   Should  it  be attended with too much 
SALIVARY FISTULAS.
29
difficulty to  penetrate through the mouth, Louis  proposes that we
should immediately introduce the probe through the wound.  It must
be almost a matter of indifference, in fact, whether we enter by one
mode or through the other.
  In  this  last case,  however, the thumb should be substituted in
place of the fingers, in order to straighten the canal and to incline its
orifice forwards when the probe is about coming out; not because it
makes an angle while it traverses the buccinator muscle, as is gene-
rally thought with Louis, but because it falls at an acute angle on
the mucous membrane, which shuts it up in  great part and appears
to throw its aperture backwards to the extent of a line.  As soon as
the saliva passes freely into  the mouth, and  the  ulcer has become
contracted up to the periphery of the meche, the seton is  to be re-
moved, or what is preferable it is to be  divided upon a line with the
integuments, in order to draw it towards us by its buccal extremity
to the distance of about a line, and not to take it away entirely until
after having completely closed the fistula by means of repeated cau-
terizations and drying applications.
   F.  Seton through a new duct.—If it were always easy to find the
anterior end of the divided canal;  if it were not  that this canal in
most  cases  has been for a long time obliterated when the physician
is called for; if, in fine, its preservation  was  a matter of much im-
portance, the process of Louis accurately imitated from the method
of Mejean in the  treatment  of fistula lachrymalis, would certainly
have  obtained unanimous concurrence ;  but this is not the case, and
the following is the method which almost all operators at the present
day have recourse to.
   I. Deroy, who, according  to Saviard, appears to have invented
this method, pierced  the cheek through and through with  a hot iron,
thus obtained a loss of substance and cured his patient.  Cheselden a
short time after gave the same advice.
   II.  Duphenix adopted a mode somewhat different.   He made use
of a long and narrow bistoury; plunged  it in from above downwards
and from before backwards; made it turn several  times upon its axis
in order to round off the opening which he  had just made;  intro-
duced in its place a canula shaped like the point of a pen which was
designed to conduct the saliva into the mouth, and the outer extrem-
ity of which, concealed in the cheek, was made to correspond with
the parotid opening of the fistula.   The borders  of the ulcer were
then excised, and in  order to shut it up Duphenix immediately had
recourse to the twisted suture.  The canula left to itself came away
on the sixteenth day, and the cure was thus accomplished.
   III.  According to  Monro  the cautery of Deroy and the bistoury
of Duphenix are advantageously replaced by a shoemaker's  awl.
By means of this instrument, which the  celebrated surgeon of Edin-
burgh appeared to have a great regard for, he traversed the cheek in
the natural direction of the canal and contented himself, for a seton, with
a thread passed  into the wound.  When its track was thereby ren-
dered callous he removed  this thread, ascertained that the saliva ran
into the mouth, and then paid attention  to the small  external  ulcer.
   IV. Plainer, who was a warm advocate of this  mode of operating,
recommends that  the patient should  be made to use a gargle of 
30
NEW ELEMENTS OF OPERATIVE  SURGERY.
brandy, in  order  to accelerate the induration of the  internal orifice
of the' new duct, and that we should at  the same time compress the
wound on the exterior or touch it with the nitrate of  silver.
  V.  J. L. Petit, after having traversed the  parts, recommends that
we should  enlarge the buccal opening  of the  perforation by daily
introducing  into  it a  small  piece of  sponge until  the fistula is
closed up.
  VI. Tessart as soon as he had passed a simple thread through the
cheek perceived that the saliva flowed into the mouth.   The use of
a few strips of adhesive plaster proved sufficient to close up the ulcer
promptly.
  VII. Flajani recommends that we should pass a double silk thread
through the fistula by means of a needle, and that  in other respects
we should proceed after the manner of Monro.
  VIII.  Desault, in a patient who could not support  compression,
made use of a hydrocele trochar to pass the thread  through the
cheek, fastened a meche to the internal extremity of this thread, and
drew it  from the mouth to the bottom of the fistula, in such manner,
however, as not to interfere with the cicatrization.  Withdrawn and
replaced each day of a  little larger size, the meche was abandoned
some few days before the  thread which  supported  it, and when the
wound had become almost entirely closed.
  IX. Bilguer like Desault had recourse to the trochar;  but in place
of the seton he left a leaden canula permanently in the inner half of
the wound, which he closed up outside.
  X.  Richter placed in the  mouth a piece of cork in order to sup-
port and receive  the point of the  trochar; made use of a seton of
thread,  the  size of which was  gradually increased ;  withdrew it
when the new canal was sufficiently solid; afterwards cauterized
the exterior wound or scarified it, and then reunited its borders.  In
the most obstinate cases  he  introduced  through the mouth into the
artificial duct, and left there permanently, a gold or silver  canula
provided with a head, in order to prevent its falling out.
  XI. M. Atti more recently, in 1824,  intending to  improve upon
the process called Beclard's, has on the other hand, rather modified
that of Desault.   By means  of the canula of a small trochar, he is
enabled to conduct through the cheek a  tent of lead, pierced on its
sides with several holes, supported externally  by a thread which keeps
it in the wound, and divided to the extent of about a line at its inter-
nal extremity into three branches, which being bent in the mouth,
hinder it from being  drawn upon  by the  thread.  When the fistula
is sufficiently reduced, M. Atti touches it with the lapis infernalis
after having removed the thread, or  even endeavors to close  it up
entirely.  The leaden tent abandoned in the cheek leaves behind it
in escaping into the mouth, at the expiration  of a certain time, a new
canal, which perfectly replaces the  old one.   The  successful re-
sults which the author brings to the support of his method  confirm
in fact its value, and his process is without contradiction one of the
most certain that can be imagined.
   XII.—It is for  example assuredly preferable to that of AT. Ch.
Bell, who like Flajani passes a needle through the  cheek in order to
introduce a thread and afterwards a seton into the fistula ; and who 
SALIVARY FISTULAS.
31
when the  internal opening of the wound has become callous, fastens
a hair or very fine thread to  the  external extremity of the first
thread,  and  afterwards  proceeds in the manner of  Desault and
Bilguer.
  G.  Internal tent.—Since the  last  thirty years, surgeons with the
hope of rendering the operation more prompt, and of being  enabled
to unite the wound by first intention,  have turned their attention into
another direction.
  I. M. Langenbeck, rejecting every kind of foreign body, has pro-
posed to dissect and to isolate  the posterior extremity of Stenon's
duct, then to  make  at the bottom of the fistula an opening which
would allow of its being conducted into  the mouth, and in order to
fix it in its new  relations to unite immediately the borders of the
wound.  But I am not aware that this professor has up to the present
time had any imitators, nor should he have any in future.
  II. M. Latta says that the best mode of curing salivary fistulas,
consists in passing a catgut through the cheek, after which we should
endeavor to  introduce its external extremity in the  parotid duct,
leaving the other in the mouth, and closing up the wound accurately,
either by the  suture or adhesive plasters ;  as if it were a thing that was
always possible to find the orifice of Stenon's  duct at the bottom of
an ulcer ! Zang, however, eulogizes this mode of operating, when the
fistula is very large, and the anterior portion of the canal shut up. Only
he recommends that we should make use of the canula of the trochar
for the purpose of conducting the catgut, that  this latter should  be
shaped  into  a point at the extremity, which is to penetrate  in the
direction of the parotid, and in order that the  saliva may run along
its sides, that it should be made  so as not to fill up exactly the arti-
ficial canal.
  III. In reducing the practice of Latta and Zang to  its true value
it is immediately perceived that it differs from  that of Desault or
Ch. Bell, or that of Vedrine, (Journ. de Desault, t. IV., p. 294,) which
latter traversed the bottom of the wound with a carlet needle, (aiguille
en carlet,) only in the  fact that they dispensed with retaining their
tent outside by the aid of a foreign body;  which enabled  them to
close up the fistula  immediately, and to do this, whether they suc-
ceeded or not in placing one end of the catgut in the natural duct of
the gland.   It is, however, possible that we may cure by this  mode,
as by most of the processes which  have been pointed out above;
but it has the disadvantage of not holding the seton sufficiently secure
in the thickness of the cheek, and of enabling it to escape too soon.
  IV. The same objection may also be  made  to  Percy, who on his
part states that he had often succeeded  by  making use of a leaden
sound, instead of the catgut which the  Germans employ.  Without
claiming  any pretension to  it,  M.  de  Guise,  (Bull, de  la Fac. de
Med., 7 annee, p. 40—44,) proceeded in the following manner in a
young patient in whom the fistula, which had already existed a long
time, had resisted a greatest variety of means resorted to.  A hydrocele
trochar inserted through the wound from without inwards, and from
before backwards, enabled him to introduce into the mouth a leaden
wire through the canula of this  instrument.  By means of a second
puncture  in  the  direction of the natural canal, that is to say, from 
32
NEW ELEMENTS OF OPERATIVE  SURGERY.
 behind foi wards and always from without inwards, he was also  en-
 abled to b-ing the other extremity of the metallic wire into the buc-
 cal cavity, reverse its two portions upon the inner  surface of  the
 cheek, and  then unite the  exterior wound by means  of the twisted
 suture.   At the expiration of a few days the agglutination appeared
 complete.  The leaden noose, whose convexity corresponded to  the
 fistula, and which included  in its concavity the internal tissues of the
 cheek, was cautiously withdrawn, and from  that  time the cure was
 no longer doubtful.
  V.  Three observations related  under  the name of Beclard, prove
 that this surgeon  frequently imitated M. de Guise wuh success.  In
 place of leaving  the  two extremities of the leaden wire free in  the
 mouth, he united them and twisted  them upon themselves, with  the
 view  of gradually cutting through the intervening tissues, as in  fis-
 tula in ano.   Moreover, in  order  to make the second puncture, he
 introduced  the trochar through the mouth, in  order that the beak of
 the canula might not prevent  its being withdrawn through the same
track  after having adjusted  the other extremity of the tent;  which
is not practicable when it is passed from the exterior to the interior,
as it is the first time.
  VI. M. Grosserio, finding that it was not as easy to pass the tro-
char through the mouth as it was through the wound, and desirous of
remedying  the  inconvenience pointed out by Beclard,  has recom-
mended a trochar provided  with a canula which is  wholly devoid of
any shoulder.  By means of this  modification we  withdraw it with
full as much facility through  the mouth in the second stage of  the
operation as through the wound in the  first stage.
  VII. Finally, M. Mirault, who  has  since recommended the same
course, considers that  a meche of thread would be preferable to a
leaden wire, and that  by means of a knot-tightener, made like that
of Desault, we would  more speedily accomplish  our object than  by
simple torsion.
  VIII. M. Roux, (Journ. Heb., t.  II., p. 178,)  governed by the same
idea as M.  Mirault, made  use of a silk seton with entire success.
Finally, 37. Vernhes, (Revue Med., 1830, t. IV.,)  has  been no less
successful with a  gold  wire,  placed  from above  downwards, not
transversely,  as recommended  by M.  de Guise, and which he em-
ployed like Beclard to cut through the  intervening tissue by twist-
ing it  gradually upon itself.
  IX. Perhaps also we might confine ourselves to perforatino- in any
manner whatever  the parotid duct  posteriorly at  a short distance
from  the fistulous orifice, and to establishing on the track which the
saliva takes  an  internal fistula  in order to be enabled to close that
which is outside.   But this process which I proposed in 1823 has
not yet been put to the test, and the facts of Trecourt, (Mem.  de
 Chir., p. 71,) or of Charve, (Lombard, Opusc. de Chir., p. 24,) which
have reference to  it, are not very conclusive.  Like  that of M.  de
Guise and all  its modifications, moreover, it would be applicable only
in cases where the wound of the duct has not approximated too near
to the masseter muscle.  Also, in order to determine the relative va-
lue  of so many different methods, it would be necessary to exhibit
all the modifications which salivary  fistulas  may present.   In this 
RANULA.
33
 point of view theie are none of them which may not have their ad-
 vantages.
 / J?-" APP™ciation.—Nevertheless, the portion of quill of Ravaton,
 Ku Z' ^^fe  P. 571,)  the  seton, after the manner of Desault, or
 Ch. Bell the leaden tent of M. Atti, or that of Percy, Latta, or Zang,
 are, all things being considered, the best, and ought to be preferred.
 lo proceed  in the manner of M. de Guise or Beclard, in adopting
 the modification proposed by M. Grosserio, it would be j-equisite that
 the fistula should be sufficiently remote from the masseter muscle.
 Under such  circumstances  this  method is the most certain, and un-
 questionably the best of all.

                   §  III.—Sub-maxillary Gland.

   If if should happen as in instances  which are on record, that a
 wound or ulcer  in the  sub-hyoid region  has extended as far as the
 sub-maxillary gland, and  remained fistulous as in the  case of Muys,
 (Obs. de Chir. dec. 6, obs. 4,  p.  341,) or that of Lecat, (Suppl. a la
 Chir. d'Heister, t. V., p. 214,  in 8vo.) we should be obliged, in order
 to effect its cure, to make trial  of all the methods which have been
 passed  in  review in treating of fistulas of the parotid gland.  M.
 Larrey, (Acad. Roy. de Med., 27th March, 1827,) abraded  its bor-
 ders, applied the  quilled  suture and succeeded.  If it was  found im-
 possible to dry up the source of  an ulcer of this kind; if, moreover,
 the secreting organ itself was profoundly altered and threatened with
 a serious degeneration, extirpation, which Pouteau ventured to recom-
 mend for the parotid, would  here be a last resource, which should
 not be neglected.   Should,  says Rossi, (Med. Operat., t. I., p. 258,)
 cauterization and compression not succeed in  fistulas of the duct of
 Wharton, the sub-maxillary gland must  be extirpated.  M. Amussat,
 (Acad. Roy.  de Med., 27th March, 1827,) who considers  that  he has
 performed this operation, states that he  has every reason to be satis-
 fied with  it.   We  shall hereafter speak of the course that is to be
 adopted under such circumstances.

             Article VI.—Ranula, (Grenouillette.)

  Ranula is a disease of little importance, and one which,  as Boyer
 says, is not dangerous.  It has, however, been seen on more than one
 occasion to compromise the life of the patient, and in all  cases it is suf-
 ficiently annoying to induce us to devise some mode of relief.   F. de
 Hilden speaks of one which filled the entire mouth; and Marchettis
 of another which was so  large  as  to compress the carotid arteries
 and the trachea.  Alix  states  that he operated upon one in a child,
 which was  upon the point of producing suffocation, and  Taillardant
mentions another which was  of so large  a size that it  prevented
the patient from eating.   A. Burns speaks of an adult man  whom
he saw in the practice of Cline,  and whose respiration was so much
interfered with by the presence  of a ranula that he swooned away
after having  been attacked with violent convulsions.  A  man who
came, in 1837, to the public consultation at the hospital of La Cha-
rite, had a ranula which, occupying the totality of the left  parotid
  vol. in.                       5 
34
NEW ELEMENTS OF OPERATIVE SURGERY.
 and supra-hyoid regions, must have contained near a pound of fluid.
 I have seen two other cases in which the mouth was as it were filled
 up by them.   Though  the ancients were but imperfectly acquainted
 with" the nature of this disease; though some  make  of it  Math Cel-
 sus  an encysted  tumor, and that  others with  Aetius ascribed it  to
 a  varicose" dilatation of the sublingual  veins, or with Abu 1  Ka-
 sem to cancer, or with Paracelsus considered it to be an apostema
 of the vesaels of the tongue, or with Aranzi  an ordinary abscess;
 they nevertheless attempted  its cure by almost all the different means
 employed since  the time that Louis endeavored to prove that it
 is  nothing  else but a tumor produced by an accumulation of saliva,
 either in the maxillary gland itself,  transformed into a cyst, or in its
 excretory duct, which  has  been enormously dilated.   MM. P. Du-
 bois and Stoltz (Gaz. Med., 1833, Novembre ; Journ. des Con»n. Med.
 Chir., 1.1., p. 182,) have each given an  example to prove that ranula
 is sometimes congenital, and that it may occupy the sublingual gland.
 In place of pure and limpid  or inspissated saliva, mucus or purulent
 matter, or a viscous substance of more or less consistency, the dis-
 eased pouch is sometimes filled with gravel, sand, or even legitimate
 calculi.  In a case related by Tulpius it was composed of  a concre-
 tion  so hard, that it became necessary to use the actual cautery  in
order to destroy it.  Schultz,  E. Koenig and V. Rieddlin, mention
facts of the same kind, which have  also been met with by J. L. Petit,
Freeman,  Sabatier,  Taillardaut, Loder and Boyer.    M.  Walther
 (Revue Med., 1826, t. II., p.  142,) asserts  that he has, in two instan-
ces,  found  calculi in Wharton's duct.  An analogous fact has been
since published by M. Baker, (New  Amer. Archiv., &c, p. 249, July,
 1835.)  The diagnosis was clear in all  these cases.   An incision of
 sufficient extent upon the tumor allowed of the extraction of the
foreign bodies, and the cure was  speedily accomplished.   Ranula,
 (grenouillette,) properly so called, requires other precautions.   Ex-
 perience has shown that, whether, after  the example  of  La Faye,
 {Journ. de Connais. Med. Chir., t.  I., p. 182,) we admit two species
of it, one for the sublingual gland, and the other for Wharton's duct,
 or whether on this point we concur with the general doctrine, the
 evacuation of the liquid will not be found a sufficient  preventive of
 a second obstruction.   For  the treatment of this disease, incision
 caustics,  tents,  dilatation, excision, extirpation, permanent canulas
 the seton, &c, have each in turn had their partisans.

                             § I.

  Incision, which first presents itself, immediately empties the tumor
 and  appears to  cure the disease.  The  organism, moreover, must
 have first suggested this idea, inasmuch as ranula a^ery frequently
 bursts of itself.   Hippocrates  had already recommended  it,  and
 effected it by means of a lancet.   Celsus  and Aetius speak of it but
 do  not appear  to have any great  confidence  in  it,  any more than
 Rhazes, who had his fea-s  on this subject, from the vessels which
 the  bistoury may at  the  same time wound.  Abu'l Kasem,  though
 somewhat bolder, did  not venture to have recourse to it except for
 subungual tumors that were of a whitish color and fluctuating, seeing 
RANULA.
35
that by cutting into the otners we incurred the risk of making them
 ass into a cancerous condition ; that is to say, that Abu'i Kasem had
 een led, without  knowing it, to distinguish the legitimate grenouil-
lette from the tumors with which it  was in his  time  confounded.
Paracelsus, in place of plunging  the instrument into the  cyst itself,
confined himself to  opening the  vessels which go to it, "and can
scarcely therefore be considered among the  number  of partisans
for the incision of ranula.   When a fluctuation is perceived in  it,
Aranzi, who does not distinguish it from abscesses, recommends that
it should be opened with the phlebotome, and  P. Forrest says that it
does not return if,  after having incised it, the surgeon takes care to
make pressure upon it, and to expel all its contents.  According to
Bartholin, Six waited until the inflammation in the tumor had ceased,
when he pierced  it through and through, in order to evacuate the
contained matter.   Jourdain,  notwithstanding the arguments of  V.
D.  Wiell, and the experience  of every day, still  maintained, about
the middle  of the last centiary,  that a free incision by means of the
lancet very frequently effected  a cure of the grenouillette, and that
we may confine ourselves to this remedy.  There are, in  fact, patients
who have been in this manner permanently cured of their disease;
but all the world,  at the present day, agree that this remedy is only
palliative, and that in general the salivary cyst is not long in again
becoming filled up.

      §  II.—Catheretics, (catheretiques.)—Injections.—Tents.

  Paracelsus,  in order to retain for the operation a part  of its ancient
simplicity, to prevent the wound  from closing up too rapidly, and to
effect in  fact a cure which incision alone was far from always obtain-
ing, maintained in the wound detergent substances ; Purmann intro-
duced styptics into it and was successfully imitated by V. D. Wiell;
Camper touched it with the lapis infernalis, and Acre!  left init a roll
of lint saturated with the spirit of salt; while Callisen recommends that
we should place in it lint only or cauterize its  bottom with a mineral
acid ; which causes, he says, the  cyst  to become detached and ena-
bles us to remove  it.   A surgeon of Saltzbourg, quoted  by Sprengel,
found it more convenient to inject  into it camphorated  spirits or
essence of turpentine and cured  his patient.   It was the  same with
a patient mentioned  by M. Haime, of Tours, (Precis Med. d'Indre
et Loire, 1821, 2nd trim.,) and whom this physician cured by means
of injections, thereby inducing the adhesion of the walls of the cyst.
Leclerc  had not been less  fortunate with the nitrate  acid of mer-
cury, and the  case of Sabatier proves that  a tent of lint renewed
or  cleaned  each day,  suffices after the incision of the ranula to ren-
der the wound fistulous  and to effect a radical cure.  Nevertheless,
as it not unfrequently happens that the disease resists all this combi-
nation of remedies, it has been proposed  to destroy a portion of the
sac of which  ifris  constituted.   I am in  truth surprised that no one
up to the present  time has applied to salivary tumors  the puncture
and irritating  injections  used in  hydrocele.  Everything, for exam-
ple, induces us to believe  that  iodine injections would prove suc-
cessful. 
36
NEW ELEMENTS OF OPERATIVE  SURGERY.
                      § III.—Cauterization.

   Caustics were employed  at the time of Aetius.  Dionis gave the
 preference to a mixture of sulphuric acid and honey, but the hot iron
 has found a greater number of partisans than escharotics, properly
 so called.  These last, in fact, are less easily managed, less sure in
 their action, and almost always dangerous when  applied upon so
 delicate a region as the mouth.  Pare, who had fully experienced
 the inconveniences of this remedy, proposed to plunge into the tumor
 a species  of trochar heated to a white heat,  passing  it through a
 metallic plate  destined to  protect the surrounding parts.   In this
 manner he obtained a loss of substance, the wound remained  fistu-
 lous, and the grenouillette did not return.  F. ab Aquapendente passed
 his cautery through a  perforated canula.   Louis gives nearly the
 same advice, that is to say, he prefers the actual cautery to the cutting
 instrument; only he makes the remark that by placing the opening
 of the cyst in front, we incur the risk t>f seeing the saliva  issue out
 and  escape involuntarily from the mouth.  Nevertheless cauteriza-
 tion is rarely employed at the present time,  as much perhaps because
 of the fear that it occasions to  the patient as owing to its not being
 always infallible.   M. Larrey, (Clin. Chir., t. II., p. 48,)  who recom-
 mends  that the incandescent cautery should  perforate the tumor
 through and through, is almost  the only person, with the exception
 of M.  PI. Portal, (Gaz. Med., 1834, p. 540,) who continues to  give it
 the preference.
                        §  IV.—Excision.

   Tulpius, J. L. Petit, Desault and Richter, desirous of systematiz-
 ing the process of La Cerlata, who hooked up the ranula with  an
 erigne and  excised it with  a razor, or that of F. ab Aquapendente,
 who seized it with the forceps and divided it with the scissors or ap-
 plied the ligature to it, have endeavored to prove that by removing
 a flap of sufficiently large size from the cyst, the tumor is  scarcely
 ever reproduced.  The fact is, that in his practice at the  Hotel Dieu,
 Desault  almost always succeeded by this method,  one which m'
 Coley  (The Lancet, 1828, vol. II., p. 495),  states that he  had had
 every reason to be satisfied with, and which Boyer, who  never prac-
 tised otherwise, had the highest opinion of.   It is the method adopted
 by M. Graefe, (Revue Medical,  1830,  p. 143,) who in this manner
 removes half of the cyst.  It is moreover performed in various ways.
 The most simple and surest mode is the following:  the  iaws  of the
 patient  being separated as much as possible, the  surgeon  provided
 with a straight  bistoury commences by making a semilunar incision
with its convexity outwards, upon almost  the entire surface  of the
 tumor facing the gums ; he then seizes with a good pair of dissecting
forceps the  flap thus cut, and detaches it  by means of the scissors
while giving it an elliptical form.  In general  no vessel of any im-
portance is wounded.  It is rare that there are more than a few drops
of blood or that the patient experiences any pain.  Dressings are
useless, and the wound which diminishes  from day to day without
however entirely closing, prevents any return of the disease, at least
in most cases. 
RANULA.
37
                        § V.—Dilatation.

  Though the disease in general is owing to the course of the saliva
being inteirupted, and though Louis, (Mem. de VAcad, de Chir., t. IX.)
imitated by Leclerc, may have  succeeded in clearing out the Orifices
of Wharton's ducts, which seemed like two aphthae on the sides of the
frenum, and that he has been enabled to dilate them by placing a sound
in them, and that the patients thus treated have  recovered; it must
nevertheless be conceded with Richter, that dilatation  in such cases
would be a most uncertain resource, one that was exceedingly diffi-
cult, and often even wholly impracticable.   Excision after the man-
ner of Boyer has undoubtedly immense advantages over it, without
exposing to the same manipulations and difficulties.

                    § VI.—Permanent Canula.

  This has not prevented some modern operators from pronouncing
in favor of incision, which they have  thought  could be made more
efficacious  by combining it with  the employment  of  a canula left
permanently in the  opening of the  cyst.   The idea of a combination
of this kind had not been mooted before the time of  Sabatier, though
this  author himself speaks only of a canula left in the wound a suf-
ficiently long time  to render it callous.   But in his time it had evi-
dently suggested itself to the minds of some other practitioners, inas-
much as he speaks  of a patient who had worn one  for three years,
and  whom he recommended to keep it in still longer.  This instru-
ment, which was about an inch long, and having on one of its ex-
tremities a lenticular button, which prevented it from penetrating too
far forward, did not produce  any serious inconvenience,  either  to
the speech or mastication of the person who wore it.   Lecat (Rich-
ard  de Hautsierck,  t. I.,  p. 403, pi. 408) cured a patient of  grenouil-
lette by means of a  short canula contracted in its middle, and termina-
ting in a shoulder on one extremity, and like the spout of a  watering
pot  at the other.  This is the canula that Dupuytren (Bull, de la Fac.
de  Med., t. VII., p. 65) has modified in  an ingenious manner, by
making it still shorter, and terminating it by a lenticular plate at its
two extremities.   This professor,  after having  opened and emptied
the  cyst, inserted  into it one  of  the extremities of his instrument,
 while the other remained in the mouth.  The tissues which embrace
 its neck, soon become sufficiently contracted to prevent its becoming
 afterwards displaced either in one direction or the other.  The saliva
 escapes  through its canal, and the patients keep it in as long as is
 judged proper, sometimes  even  during their  whole lives, without
 being in reality  incommoded  by  it.   Dupuytren  recommends that
 the  buttons of his canula should be of gold, silver, or platina, and that
 they should be convex on their free surface only, and concave within,
 in order that the food may not  become caught between them and the
 walls of the  cyst.   There is  no objection in fact to making trial of
 this method, which, according  to the  editors of Sabatier, succeeded
 constantly at the Hotel  Dieu:   But I do not perceive in fact that  it
 possesses any particular advantage over  simple excision, which, on 
38
NEW ELEMENTS OF OPERATIVE  SURGERY.
the other hand, was  rarely attended with  failure in the hands of
Boyer.
                         § VII.—Seton.

  It is seen from this review that the treatment of grenouillette is
entirely based upon  that of hydrocele,  as  M. Haime  has likewise
remarked, and also Purmann, who had already endeavored to effect
adhesive inflammation of the salivary  cyst in the same  manner
as we do adhesive inflammation of the tunica vaginalis.   There re-
mains the seton, which might be employed with some prospect of
success, if the other method were not infinitely more  rational.  This
resource, however, possesses a certain degree of efficacy, as is proved
by  the practise  of Physick, (Dorsey's Elements of Surgery,) who
was long in the habit of employing it, also by the observations of M.
Lloyd, (Lancet, 1828, vol. II.,  p. 495.) who  also made use  of it  at
London, and the memoir published by M. Laugier, (Journ. Hebdom.,
t. III., p. 9.)   The presence, moreover, of a foreign body of the
smallest size in the  salivary ducts, is sufficient to produce accidents
of quite a serious character.  We have  seen above,  that saline con-
cretions and various kinds of calculi sometimes form in these organs.
A disease of the mouth, which resisted every treatment, disappeared
after the  extraction  of a fish bone, which had got introduced into
Stenon's  duct, (Revue  Med., 1831, t. II., p. 373.)  A similar thing
took place in a shoemaker mentioned by M. Robert, (Ibid., t.  II., p.
374,) who had a hog's bristle in Wharton's duct.   A  piece of straw,
which had  entered  into this canal, caused various accidents  there,
and abscesses which were not cured  until after the expulsion of the
foreign body, (Gaz.  Med., 1838, p. 793.)

                     § VIII.—Extirpation.

  Loder and  Sabatier have seen the disease resist  these different
modes  of treatment, and  many authors had  already contended that
the surest mode is to extirpate  the  grenouillette or to  destroy  it
entire by means of  caustics.  Celsus, in a rather obscure passage  in
his  works, would lead us to believe that he himself was acquainted
with this extreme remedy.  Treating of sublingual  tumors, he re-
commends when they do  not yield to puncture, that we should incise
the skin that covers them, in order to extract them, taking care not
to  wound the vessels, while  an assistant  separates  the lips of the
wound.   Mercurialis,  the first author who distinctly recommended
it, raises up the tumor with an erigne, cuts it at its base in the mouth
and says if we do not destroy the whole cyst, the disease is  sure to
return.  Diemerbroeck commenced by making a  crucial incision into
it, and then extirpated the whole of it.  Alix, without going as far
as  this, incised it largely,  but lengthwise, and then removed as  much
of the cyst as  he could by means of the scissors.  Marchettis who
in  a very severe case had introduced  a  meche as  far  as into the
mouth,.by penetrating through the supra-hyoid region, was, never-
theless, obliged to extirpate as much  of  the tumor as he could and
to  destroy the rest  with  a hot  iron.   It appears, nevertheless,' that
complete extirpation was but  rarely performed by  these different 
TUMORS  OF THE MOUTH.
39
practitioners.  It scarcely ever becomes indispensable unless the evil
should threaten  to take on a serious degenerescence, or to be trans-
formed into a solid tumor.  Otherwise, all that is actually necessary
is, to excise the portion which projects into the mouth;  so much the
more so, because by then touching the bottom  of the wound some-
what actively with the  nitrate of silver, its exfoliation is readily ac-
complished.  An enormous cyst  occupied  the entire  supra-hyoid
region;  M. Malcolmson  (Gaz. Med.,  1838, p.  743,)  excised an
ellipse from it, and the gland was seen  at the bottom; he then excised
this, and extirpated  it nearly entire, when  the patient recovered;
but I  am not satisfied  that the  lymphatic ganglions may not have
here  constituted the great bulk of  the disease removed.

             Article  VII.—Tumors of the Mouth.

   Tumors  that are salivary, at least  in appearance, are sometimes
encountered elsewhere than on the  sides of the tongue.  I treated
at the Hospital St. Antoine, a  patient  who had had one of these for a
long time, between the lip and the  left superior alveolar arcade, and
who procured relief  every month by plunging into it a  bistoury or a
lancet.  M. Graefe states  that he has  often met with them in the sub-
stance of the lips.  Wilmer mentions  one, which was situated in the
lower jaw; and Dupuytren, as well as Runge, (These de Holler, 1.1.,
French translation,) have frequently seen them in the substance even
of the bones. The one which M. Latour, (Arch. Gen. de Med., t. VIII.,
p. 52,) had under treatment, occupied a large portion of the  cheek,
and M. Ricord, (Ibid., t. VIII., p. 527,) has published under the title
of hydatid  of the canine fossa, a case which probably belongs to the
same  kind of lesion.   All the processes  above pointed out are appli-
cable to these tumors ;  but when we are desirous of obtaining a rad-
ical cure, it is advisable to have recourse to simple  excision, con-
joined with cauterization, or to extirpation.  These tumors, filled with a
viscous yellowish or transparent liquid, are not rare. I have seen them
in the tissues of the cheeks and lips, between the gums and cheek, as
well as between the gums and tongue, and without any communication
whatever with the salivary ducts or glands.  M. A. Berard,  (Arch.
Gen. de Med., ser. III., 1.1., p. 402,) extirpated one which was of the size
of an egg.   A concrete tumor was situated between the tongue and
the jaw; to  remove it entire with greater facility, M. Roux, (Mercier et
Vigla, Journ, des  Conn. Med. Chir., t. IV., p. 104,) divided the lip
vertically and found  it  necessary to saw through the  inferior max-
illary bone  on the  median line.  It became  necessary  to await the
exfoliation  of some splinters, but the  operation  was followed with
entire success.  The  wounding of the salivary ducts may also  give
rise to tumors of this description, even upon the track of Stenon's
duct.   M. Verhnes has publishad  an interesting case  of this kind,
which must be classed  with that of M. D. Lasserve ; in consequence
of a traumatic lesion, there formed upon  the inside of the cheek a
small oblong tumor  filled  with saliva, and which  M. Verhnes  suc-
ceeded in curing by passing through it a small trochar, attached to
which was  a double gold wire, which he employed in the manner
of a  seton.  If a case of this kind should again present itself 
40
NEW ELEMENTS OF OPERATIVE  SURGERY.
 the method of this surgeon  ought to  be adopted, unless we  should
 prefer to confine ourselves merely to the process of Beclard for sal-
 ivary fistulas, or to the treatment of grenouillette.

                  Article  VIII.—The Tongue.

              $ I.—Operation for Filet, (Tongue-tie.)

  The species of fibro-mucous fold which  attaches the  free portion
 of the tongue to the posterior surface of the chin, and which is
 called frenum when its dimensions are properly proportioned, takes
 the name of Filet, when it is too long from before backwards, or too1
 short from above  downwards.   It then  becomes impossible for the
 infant to suck.  The point of the tongue being then arrested against
 the lower wall of the mouth, renders it impossible  to draw it out-
 wardly, in order to seize the nipple.   This is an arrangement, there-
 fore, which might be attended with serious consequences, if we did
 not immediately attend to  its removal.  Only that  we should be
 careful not to suppose that the infant is tongue-tied as soon as it does
not suck, or is  a long while  in  beginning to  talk.  Such accidents,
which a thousand different causes may occasion, do not depend upon
the  frenum of the tongue, unless it be found that when the finger is
passed into the mouth, it is impossible  to be seized hold of by it, or
that its point cannot  reach as far as On the lips, in which cases only
we  should undertake the section of the filet.
  A. There is nothing to show, unless it be a  remark in Cicero, that
this small  operation had  been described before  the time of Celsus,
who, in order to perform it,  recommends that we should raise the
tongue with the forceps, and already at that  period advises that we
should be careful not to divide its vessels.  Paul of Egina and Abu'l
Kasem employed  a hook in place of the forceps.  Avicenna, in order
to be more  certain  to avoid  any hemorrhage, passed a  ligature
through the  base  of the frenum, and in this manner dispensed with
the  cutting instrument.  De  la Cerlata, who censures midwives for
tearing out the filet  or dividing it with their nail, destroyed  it by
means of a particular instrument, and raised up the tongue with his
two fingers.
  The sharp-pointed scissors of Friederich are justly condemned by
 Fabricius  ab Aquapendente, who severely censures the pernicious
 practice of midwives, already pointed  out by De la Cerlata, and
 moreover  remarks that this operation  is  rarely required.   F.  de
 Hilden is  of the  same opinion, and  performed the operation with a
 deft instrument, which served at the same time as a scissors and as
 a fourchette to raise up the tongue.  The instrument of M. Montain
 (Mini, de  Therap., 1836, p. 34,) is nothing more than an  improve-
 ment of that of F. de Hilden.   The blunt fourchette and the large
 scissors devised by Scultetus and Solingen are useless.   The idea of
 cutting  the  filet with a  bistoury heated to  a  white  heat, as was
 practised by Lanfranc, would at the present  day be considered ab-
 surd.   The spring instrument  of  J. L.  Petit, and which was  eulo-
 gized by Platner,  appeared to be attended with too much inconveni-
 ence in the opinion of Le Dran, who maintains that the blunt-pointed 
the tongue.
41
scissors will always answer, and that it is unnecessary to go to the
extent of Dionis, by lacerating the wound with the finger, in order
to enlarge it after the incision is made.   The cleft spatula of Richter
and Callisen, and the curved and blunt-pointed scissors invented by G.
Schmitt, are not in use with us at the  present day, though in fact
they might be made  to effect the object intended  by their authors.
M. Colombat, who is always ingenious  in constructing new instru-
ments, has  proposed one, which appears to me altogether useless, as
does also  the  excision which he  recommends to be substituted in
place of the simple incision.
   B.  Operative Process.—We adopt the method of Le Dran, that is
to say, the  infant being seated and its head held back by its nurse,
or some other  person  who will not be disturbed by its cries, the sur-
geon raises up its tongue by means of one or  two of the fingers of
his left hand, while with the other hand holding a blunt-pointed scis-
sors, he rapidly divides the frenum.  But, inasmuch as the size of the
fingers may frequently embarrass the remainder of the operation, we
have generally made use, since the time of J. L. Petit, of a canulated
sound, the  cleft plate of which* being  substituted  in their  place,
protects at the same  time  the vessels.  When the filet is properly
secured in the bifurcation of this plate, the operator slightly raises up
its handle  towards the forehead of the child, in order to push the
tongue backwards and upwards.   Then introducing the scissors un-
derneath,  he divides  with  a  single cut the small membrane thi
stretched, taking care to  direct the point of the instrument slightly
downwards, in order  to be sure that he runs no  risk of wounding
the ranine arteries.  The wound requires no precaution, and it is ex-
tremely rare that the little patient  suffers any pain from it beyond a
few hours.   The movements of the organ prevent its reagglutination,
and I am not aware that there is any necessity in this matter to touch
it  with nitrate of silver, as  is recommended  by M.  Hervez  de
Chegoin.
   C. Accidents.—Tetanus, which  was  produced  by the section of
the filet, in the child mentioned  by J. Fabricius, and which operation
had been performed by a charlatan, has never been observed since.
According  to  some authors, two serious accidents, hemorrhage and
reversion of the tongue into the pharynx, may however be caused
by this operation.   The  first  happened to Roonhuysen, who could
not arrest the blood until he had applied vitriol to the bottom of the
wound   Maurain  incurred still greater dangers, and was obliged to
come to the actual  cautery.   J.  L. Petit  mentions two cases in
which the operation having been badly performed, the patients would
have evidently succumbed if he had not immediately afforded  them
relief.  A circumstance which in these cases aggravates the danger is
this, that the blood in place of being spit out, is swallowed in propor-
tion as it flows, and that if we are  not vigilant the child may die be-
fore we have suspected the cause.
   I.  If  we employ the sound, and take the  precaution to  incise
nearer the inferior  wall of the mouth than to the tongue, it is next to
impossible that such a hemorrhage  can take place.  If it should hap-
pen, however,  it may be  stopped by directing upon the point which
bleeds the head of  a  probe heated  to a white heat.  J. L. Petit suc-
   VOL.  III.                       6 
42
NEW SLEMENTS OF OPERATIVE  SURGERY.
 ceeded by means of a wooden fork  an inch long protected by linen,
 and having its point d'appui against  the  inner side of the maxillary
 symphisis  on the  one part, on the other embracing the top of the
 wound, while a small band passed transversely in the  mouth, then
 brought out and crossed under the  jaw, and raised up above the
 ears  to  be fastened  to  the child's cap, hindered the tongue  from
 moving.  Two  stems united in any manner whatever at their mid-
 dle portion so as to form a forceps, by means of which the bleeding
 part should be seized, and which should  be made to act by pushing
 a wedge between the two halves of its other extremity, would bring
 about the same object, and in fact attain it with still more certainty.
 The natural softness of the tissues, and the retraction of the arteries,
 would in general  render the  ligature recommended by  Courtois
 wholly inapplicable.
  II.  As to the reversion of the tongue, the moderns  have  with dif-
 ficulty admitted  its possibility.   J. L. Petit, who has seen three ex-
 amples of it, explains  it in saying that the frenum having been di-
 vided the tongue  becomes free, is raised up and directed towards
 the windpipe with so much the more«facility, because the  infant, who,
 up to that  time  had not been  able to seize hold of the nipple,  now
 sucks upon  it with  a  degree of voracity.   In one  case, this  prac-
titioner had three times to draw back the tongue out of the pharynx,
but the fourth time the  patient died notwithstanding.  J.  L. Petit
has seen the reversion  in question during life, and has demonstrated
its existence after death.  It  is  therefore an unquestionable  fact.
Nor can I see why it  should be so difficult to comprehend, nor why
we should call in doubt what  travellers have said of those Eastern
or African people, who, in order to escape severe punishments, killed
themselves by swallowing their tongue.  Any person may ascertain
upon himself, that the  tongue  can be reversed to the upper part of
the pharynx, and that  there would be no very great difficulty in clos-
ing with it the posterior opening of the nasal fossae.  A similar fact to
those of Petit, has moreover been related since by M. Cross,  (Presse
Med., t. I., p. 388.)  We avoid this reversion by not dividing the
 filet too  deeply.  In order to remedy it we must bring back the
 tongue by means of the finger into its natural position, make the in-
 fant constantly suck so long as there is danger, and when it does not
 suck, keep its mouth carefully shut.

         § II.—Anchyloglossis, (Adhesions of the Tongue.)

  Adhesions of the tongue have at every epoch attracted the atten-
 tion of surgeons.  Whether they be congenital  or acquired, the re-
 sult of simple inflammation or the product of more deep-seated le-
 sions, ancient or recent,  the cutting  instrument is nevertheless the
 only resource for their relief.   Aetius  says  that the abnormal mem-
 brane, or cicatrix, is to be seized with a hook, and to be then divided
 with the necessary precautions.  J. Hellwig, having been consulted
 by an individual who could not articulate sounds, destroyed by dis-
 section the adhesions of his tongue, and thus restored his speech.  At
 the present day, we proceed in the same way.  Only it is important
 'hat we should  not allow ourselves  to be imposed upon by an ar- 
THE TONGUE.
43
rangement that is sometimes met with in new-born infants.   In such
cases their tongue  is merely glued  (collee) either against the vault
of the palate, as Louis has seen it, or to the lower wall of the mouth,
which has caused more  than one old grandmother to  suppose that
the  child had no tongue.  The finger, the handle of a scalpel, or the
spatula, will be found sufficient to destroy this simple agglutination,
which in fact is nothing  more  perhaps than the beginning of a true
anchyloglossis.  The method to be adopted would be still the same in
an  adult, if we should  be called before  the  adhesions, which have
been the result of a  diffused inflammation, have acquired a ceitain
degree of solidity.
  A.  If there should be  only a few bridles of slight extent upon the
sides of the frenum, we  should divide them with the scissors, like the
filet, and with the same  precautions.   We should divide in the same
manner those which are not unfrequently found to have been formed
between the cheeks  and borders of the tongue, in consequence  of
mercurial gastritis and other phlegmasias of the mouth, examples  of
which have  been  communicated to the Academy by MM. Duval,
Cullerier, and Bernard.  Should they  have  a  certain  degree  of
breadth, they should be excised in place of simply dividing  them.
After having detached them from the buccal wall by one cut of the
scissors, we should  seize them near the  tongue, in order to remove
them by a second cut with the same instrument.   We may also re-
move them by embracing them successively at their middle portion
with the forceps, while we detach their borders with the scissors  01
bistoury.
  B.  When on the contrary these  adhesions are  close, or cellular,
as it is termed, the dissection must be conducted with more particu-
larity and caution.  The surgeon  being placed behind, and to the
right of the patient, whose head is held back upon a pillow, the arm
of the nurse,  or against the chest of an assistant, endeavors to sepa-
rate by  means of the left  forefinger,  a spatula, or a portion of a
sound, or any other suitable instrument, the free portion of the tongue
from  the  point in  the mouth  which keeps it immovable.   Dividing
gradually with a straight bistoury held  flatwise, all the  lamella?  or
unnatural attachments which  he intends to destroy, and not forget-
ting, at the inferior region especially, slightly to incline the edge  of
his  instrument towards the wall of the mouth, or to remove it as far
as  the state  of the parts will permit from the  body of the tongue
itself, in order to avoid the vessels with greater certainty, he sponges
up  the blood in proportion as it runs out and stops from time to time,
in order to afford the patient time to breathe and to have his mouth
cleansed out.  He then  cauterizes with a hot iron if any hemorrhage
exist, or in other cases prescribes some styptic or astringent lotions,
and finishes by pressing his finger upon all the points of the wound
in order to assure himself that there no longer exists any improper
adhesion.   Emollient gargles, extended  and frequent movements
of  the tongue, and the precaution of frequently gliding the  finger
between the divided surfaces in order to prevent their reunion, are
all  that remains to  be  done until the cure is completed,  which is
usually accomplished from the  fifth to the thirtieth day, but which
requires all these attentions in order to be effected with certainty. 
 44            NEW  ELEMENTS OF OPERATIVE SURGERY.

           § III.— Tumors and Ablation of the Tongue.

  A. Gangrene, induration, fungous and schirrous tumors, cancer-
 ous ulcers and true cancers, are the principal diseases which  may
 require amputation of the  tongue either entire or in part.  It is  an
 operation which has been only lately introduced into practice.  De-
 terred by the idea that the tongue is the exclusive organ of speech,
 although J. Lange asserts that he had already often removed it in con-
 sequence of gangrene, this operation was thought  of only with dread,
 when Louis demonstrated  that many individuals, though deprived of
 a large portion of this organ, nevertheless  continued  to have their
 speech and to distinguish the taste of different substances.   The  la-
 borer mentioned by Roland de Saumur, and who  had lost his  tongue
 down to the root in consequence of gangrene, could speak, spit, swal-
 low  without difficulty, and taste different substances.
  The young  girl noticed at Lisbon, by De Jussieu;  the Margaret
 Cutting mentioned in the Philosophical Transactions ; the Marie Gu-
 lard  referred to by Bonami and Louis; the  girl, A.  M. Federlin,
 whose history is published  by Auran; the young man whose  tongue
 was  torn out by the corsairs because he would not be  made a Mus-
 sulman, and whom Zulpius  states he  saw, and another person who
 had his tongue cut out by robbers, and whom  Zacchias mentions  to
 have seen, were cases of this description.  It  is also known that in
 Germany, Italy, Spain, &c, it has a long time been the practice to
punish malefactors by cutting out their tongue but most of  whom,
notwithstanding, have retained the faculty of speech.  All the world
in fact are familiar with the two cases  so quaintly described by  A.
 Pare: 1st, of a mower, who after having been mute for the space  of
 three years in consequence of having lost a portion of his tongue,
 being ridiculed by  one of his  comrades while he was holding a
 wooden vessel between his teeth, made an effort  and uttered, to his
 great astonishment, a few words, and who, taking advantage  of this
 circumstance, finally learned to speak distinctly by means of a  saucer
 or small  cup; 2d, of a young boy  whose tongue had  been cut  off.
 and  who  recovered his speech by making use  of  the  instrument
 invented  by  the  preceding person.   Though it be  satisfactorily
 proved that the loss of the tongue does not always involve complete
 loss of speech, it  is  nevertheless true that its amputation has been
 more than once performed without  any very evident necessity.  We
 should dispense with it for example at the present day, and would
 not imitate Pimpernelle, (Bonet,  Corps de Med., t. IV.,  p. 305,} even
 though the organ  had become so much swollen as to protrude, out-
 side, unless it  was accompanied at the same time with an  actual
 schirrous or cancerous degenerescence.  Serous cysts, abscesses and
 collections of blood might be laid open or excised  without the  neces-
 sity of extirpating the tongue.   In a case cited by Thymoeus, (Ibid.,
 t. III., p. 201,) and in another for which we are indebted to  Bona-
 vert, (Trans. Philos. Abreg., t. IV.,  p. 340,) a tumor upon the tongue
 contained a stone of the size of an almond.   A patient of Sedelius
 (Bonet, Corps de  Med., t. IV., p. 62) presented the same phenome-
 non.   Dumonceau (Mem.  de VAcad, de Berlin, t. VII., Append., p.
 130) mentions that a retention of urine was  not removed until after 
THE  TONGUE.
45
the extraction of a stone which was found under the tongue, and we
see also in  a case  of Leautaud (Ibid.) that a similar calculus had
produced fever with an abundant salivation.   In all  cases of this
kind we should never think of amputation of the tongue.  It  is an
operation therefore which in the mam must be reserved  for cancerous
tumors, and other degenerescences of bad character.
  B.  Operative Process.—The operation, moreover, is performed in
quite  a variety of modes, and  should be modified in fact according
as the disease presents itself on this or that part of the organ.
  I. Process of Faure.—The  erigne forceps or scissors curved flat-
wise, will answer for the excision of pediculated tumors of greater
or less  size, and which rarely appear upon the tongue  except on its
dorsal surface.  The ligature would not have the same advantage,
and however little of the disease we  may apprehend to have left
behind, it is important, in addition, to cauterize the bottom of the
wound with a hot iron.
  II.  If the alteration should be confined to the tegumentary layer,
it would be necessary, as Walee,  after the manner of Bartholin,
appears  to have done long since, to remove  only the degenerated
lamellae  and to preserve the muscular tissue.
  III. Should the chancrous ulcer be deeper and situated upon the
borders of the tongue, we should then, in order to destroy it, no longer
make use of the curved bistoury, as was done by a surgeon made
mention of by Ruysch.  The point of the tongue being wrapped in a
dry piece of linen, is drawn to  the  outside  by  the hand of an
assistant, who inclines it towards the  side  opposite to that of the
disease.   The  operator, provided with  a  straight bistoury,  com-
mences  by making an incision of several lines in extent on the lower
surface   and  throughout the whole  length of the organ; makes
another  on its  dorsal surface; thus  encircles the cancer, including
with it .a certain extent also of the sound parts; then secures it with
the forceps  or erigne, and promptly completes its excision.  The
actual cautery, without being really necessary, becomes a matter of
importance at the termination of the operation, as in the preceding
case.   If, out of the  three persons operated upon in this manner by
M.  Heyfelder, (Journ. des Conn. Med., t. II., p. 347,) a cure was
effected only in one,  it was certainly not the cautery which  did it.
  IV. Ligature.—When the disorganization is still deeper, when
especially it has extended very far backwards, and that it, neverthe-
less, appears to be practicable to preserve  one of the halves of the
tongue,  we may have recourse to the ligature.  It would protect us
with  more  certainty against  hemorrhage  than the bistoury,  and
nothing prevents us, if we apply it in a particular way, to  go  back
with it nearly as far as the larynx.  A tumor of a doubtful character,
which was situated  upon the side of the tongue and which  was tied
at the supra-hyoid region, and also at the mouth, was in this manner
ultimately detached,  resulting in the recovery of the patient, (Arnolt,
Gaz. Med., 1839, p.  106.)
  a. Process of M.  Mayor.—The organ is first transfixed through
the  mouth, and at its  most  remote part, from below upwards  and
from before  backwards, by a strong bistoury, which  being  brought
forward  divides its whole length into two equal parts without touch- 
46
NEW ELEMENTS OF OPERATIVE SURGERY.
ing the neighboring arteries.   The operator then adjusts, at a point
beyond the  disease and  upon the affected portion, the  noose of a
strong ligature of thread, the two ends of which he passes separately
through a metallic  tube, of a square shape and pierced with two
openings slightly convergent, then through the other pieces of the
chapletT knot-tightener which I have spoken of in the chapter on liga-
ture en masse;  thus embracing the base of the flap  which is to be
destroyed, he turns the small winch, and when  the  constriction  is
carried as far as is desired he attaches the free portion of this appa-
ratus  to the labial commissure, either by means of  a thread or a
small  band.   The pressure is increased in the same manner daily,
and even several  times during the day.   The  tissues soon mortify,
and either separate or may be excised without danger on  the third
or fourth day.  The knot-tightener of M Mayor, which  has been
employed  in five  instances with  success by its inventor, and which
is a real improvement upon the instrument devised by MM. Bouchet
and Braun,  has  the advantage in consequence of its flexibility  of
adapting itself without difficulty to the inequalities of the tongue, of
occasioning but very little inconvenience  in the interior of the mouth,
and of allowing of a constriction which is at the same  time moderate,
energetic,  and permanent.  Should  it not be at hand, however, the
knot-tightener of  Desault or that of Levret might, in  these cases, be
employed  here with full as much advantage as  for the ligature of
polypi in general.
  b. If the whole breadth  of the tongue is diseased, either at its point
only or as far down nearly as its base,  the ligature  would still  be
applicable.  The proof of this  is demonstrated in the observations of
La Motte and  Godard, each in a different case.  Ev.  Home and
Mirault (Soc. de Med. de Montpellier, t. IV., p. 517,) passed a double
ligature through the centre of the  tongue and brought its two halves
out, to be knotted upon the sides of the organ, which they succeeded
in this manner in dividing and separating  by suppuration.  M. Galen-
zowski (Journ. de Progres, 2e serie, 1.1., p. 256,)  in order to destroy
a fungus  hematodes which occupied one  of the  sides of the tongue
employed a triple ligature and succeeded.  In place of previously
slitting through  the tongue from before backwards, as is recom-
mended by  M. Mayor, M. Maingault (Journ.  de Prog., t. XIV., p.
511, Ire serie,) proposes  that we should  apply the ligature by the
mouth and  pass  it through each  half of the tongue  on its side, by
means of the curved  needle  of Deschamps, which certainly would
be preferable if it were possible to go far enough back.
   c. By the supra-hyoid region.—I have elsewhere described, (Arch.
Gen. de Med., 2e ser., t. V., p. 638,) after having seen the operation
made trial of by M. J. Cloquet, another process,  since improved bv
M. Mirault, the son,  (Mem.  de  VAcad.  Roy. de Med., Paris, 1835,
t.  IV., p. 35.)  An incision between the os hyoides and the chin
enables us  to introduce in this manner, from  below upwards and
from  before backwards,  through the base  of the tongue, a double
ligature which is to be turned one on either side, upon each half of
the organ, in order to bring them  out  through the  same  opening
below, and to fix them with a knot-tightener under the jaw.
   V.  So long as the tumor does not  extend too far backwards, and 
THE TONGUE.
47
that it retains a small portion of sound  tissues upon its borders, ex-
cision  with the cutting  instrument is  preferable.   Louis recom-
mended, after the manner of the ancients, that after having hooked
the tongue by means of an erigne forceps, or the forceps of Museux
for example, we should  amputate it by merely cutting through it
simply and transversely with the bistoury.
  VI.  At the present time we adopt a much  more rational process.
The surgeon having seizf d the morbid mass with a strong  erigne or
hook forceps, draws it out of the  mouth  with one hand, circum-
scribes and removes it with the other by means of two cuts of the
scissors, making a V incision through the sound parts, and the point
of which faces backwards and is to  fall upon  the median line.  Im-
mediately approximating the two sides of the wound, they are to be
united by three points of suture,  one on  the dorsal surface, a second
at its point, and the third on its  lower surface.  The agglutination
is often completed by the second day.  The threads  may be with-
drawn on the third or fourth day, and the cure is generally com-
pleted from the eighth  to the tenth.   This is what has been seen to
take place by Boyer and M.  Langenbeck,  and what I  myself have
witnessed.  In this manner the deformity is reduced to as slight a
degree as possible, and  the accurate coaptation of the bleeding sur-
faces so frequently of itself arrests  the hemorrhage that it becomes
unnecessary to recur to any other hemostatic means.
   VII. Process of the Author.—Whatever process may be preferred,
a noose of thread passed through the point of the organ always sim-
plifies the operation.  By means of  this noose the surgeon does with
the tongue what he  pleases ; he  draws  it out, relaxes  it,  depresses
or elevates it, and directs it to the right or to the left, without in any
way interfering  with the movement of the instruments.  M. Diffen-
bach,  (Gaz. Med., 1838, p. 808,) who employs  two nooses of this
description, passes them behind the tumor and not near the point of
the organ.  Since the year 1831  I have  employed them in  ten cases,
and I cannot too highly recommend them to the use of practitioners.
M. Graefe (Bull, de Fer., t. XX., p. 211,)  and M. Delhaye (Journ.
 Univers. Hebdom., t. IX., p. 20,1832), have been equally well satis-
fied with them.  If the tumor does not occupy the end of the tongue,
and should it be  found  nearer  the middle than the border of the
tongue, after making use of this precaution, I hook the degenerate por-
tion with an erigne in order to stretch it and encircle it in  an ellipse
by two semilunar  incisions.   Should it become necessary to remove
one half of the organ, I first detach its lower surface transversely by
a cut of the bistoury.   The instrument  then being immediately car-
ried behind and beyond the limits of the disease, enables me to divide
the tissues from above  downwards with a  second cut, which termi-
nates the operation.  It would be difficult to find a more simple mode
or one that is more generally applicable.
   C.  Appreciation.—Transverse amputation  of the tongue therefore
should be  reserved for  those cases in  which there  is no opportu-
nity for the formation of lateral  flaps.   The  dividing the tumor  by
a crucial  incision  and then cauterizing its bottom, as Delpech  did,
(Rev. Med., 1832,  t. II.,  p. 384,) is  an objectionable process, which
would be applicable only to cvsts of a benign nature.   The method of 
48
NEW ELEMENTS OF OPERATIVE  SURGERY.
 Jaeger (Journ.  des  Conn. Med. Chir.,  t. I., p. 347), is too com-
 plicated, and requires  too many instruments to find  any advocates.
 The previous  ligature  upon  the' lingual artery, as practised by  M.
 Flaubert, and which M. Mirault has made trial of, would not be use-
 ful except, if instead of the ligature en masse, we intended to make
 the excision  at a very remote  point upon  the  tongue.   It is also
 with difficulty that I can comprehend why M. Regnoli, (Gaz. Med.,
 1838, p. 796.) in order  to extirpate  a tuiflor  from the tongue should
 have found it necessary to incise the entire supra-hyoid region and
 to draw out the tongue through this opening, though the young girl,
 who was  fourteen years of age, was cured.
   D.  When hypertrophy only exists, compression, as employed suc-
 cessfully by Freteau, (Bull, de la Fac. de Med., t. V., p. 264,) Del-
 pech (Recue Med.,  1835, t. I., pp. 330-337,)  and many others, will
 almost always answer.  M.  Rey,  (Ibid., 1835,  t. I., pp. 330-337,)
 who, in a case of this kind, states that he was obliged to have resort
 in one instance to the V excision, adds that the operation of Mirault,
 the father, was also performed for a hypertrophy, and not for a can-
 cerous tumor.   It is quite remarkable that M. Harris (Bull, de Fer.,
 t. XXVI., p. 93),  and  M.  Mussey,  (Gaz. Med.,  1838, p.  394,) who
 believe themselves to have been the first who employed thus process,
 should also have been  under the necessity of making use of the V
 excision to cure a chronic tumefaction  of the tongue.  As to the
 rest, every tumor, whether scirrhous or carcinomatous, which does
not penetrate too deeply and which projects at the periphery  of
the tongue, may be readily  destroyed  by the process  of Faure  or
 Louis,  that is to  say, by means  of the scissors curved  flatwise and
 the actual cautery.  Those on the contrary, which, extending to the
muscular tissue, are seen upon the surface or on one of  the borders,
 without reaching too great a distance posteriorly, ajnd which have not
invaded either the entire breadth or thickness of the organ, require
 the employment of the  bistoury by the process which  I have pointed
out, and which is somewhat analogous to the method of P. le Mne-
 monite.  If the disease, though  much extended on the surface, con-
 tinues to be superficial,  and that the  tissues beneath it are sound, we
 must follow the indication given by Vallee and dissect and remove
 everything which is diseased, and respect and preserve everything
 which is not so.  If it becomes necessary to destroy an entire half of
 the tongue, including therein its base, the  ligature by the process of
M. Mayor becomes applicable and even appears to me to be prefer-
 able to that of M. Mirault, while, should  it become requisite  to re-
 move  the whole tongue, the process of  Home ought to  have the
 preference, as well as in all those cases in which excision, after the
 manner of Boyer, is not sufficient for removing the tumor and cen-
tral degenerescence.   It is necessary to be remarked however, that
in the process of M. J. Cloquet or M. Mirault,  as well as in that of M.
Maingault, there is no necessity of slitting  up the whole length of the
tongue before  strangulating  its base.   I will  add,  in the  patient  of
the surgeon of Angers, the ligature, by embedding itself into the
tissues, became imprisoned there by allowing  them to reunite over
it in place of mortifying them ; the tumir nevertheless was removed 
POSTERIOR FAUCES.
49
and the tongue remained e.itire.   As to the process of M. Regnoli, I
do not know what to say of it.
   E.  Subsequent  Treatment.—It  is  extremely rare,  as  has been
shown by Tarbes, (Clin des Hop., t. II., p. 41,) that we are under
the necessity, after these different kinds of operations* of having re-
course to the various objects of dressing.  If the contrary should be
the case, the gusset (gousset) of Pibrac might become useful.  Upon
the supposition  that there should occur  an unpleasant hemorrhage,
or one which the means above pointed out could  not have effectu-
ally arrested, we should then have to have recourse to the ligature.
In such cases we should be obliged to look for the lingual artery at
its passage above the os hyoides, unless that the carotid itself would
not also  have to be  included  in the thread.  It would, in  fact, be
advisable to commence there if the tongue was  to be amputated
near its  root  with the  cutting instrument.

                         §  IV.—Palate.

   The mouth and the  palate, as well as tongue and cheeks, some-
times contain calculi.   Kruger (Mem. de TAcad. de Berlin, t. VII.,
App., p. 130,) says  he  extracted a  calculus from  an abscess in  the
palate.   A stone came out from the internal surface of the masseter
in a patient mentioned by D. Pomarest, (Bonet, Corps de Med., t. IV.,
p. 102.)   The vault of the palate is sometimes also the seat of fibrous
or cancerous  tumors.   I have already given two examples of these
in the chapter on tumors.  M. Guyot (Bull, de Fer., t. II., p. 262,)
has successfully extirpated tumors of this kind, which did not differ
from ordinary cancers.   I have met  many instances of those which,
of the size of the thumb or a small egg, presented all the characters
of fibrous  tumors, and were solidly  adherent to the bones.  To  re-
move them, all that is necessary would be, after having hooked them
with an erigne, to dissect them  with care, and afterwards to cauterize
the wound with  the red  hot iron should any hemorrhage threaten.

      Article IX.—Posterior Fauces,  (Isthme du Gosier.)

                  §  I.—Hypertrophied Tonsils.

  The tonsils, after  repeated  inflammations,* frequently remain so
large as to interfere with deglutition,  hearing and respiration.  The
induration they acquire at the same time, is the  reason why for cen-
turies past it has been believed that they had passed into the state of
scirrhus.   But since the time of Claudinus, and especially of B. Bell,
the falsity of this  opinion, which I am surprised to see revived in
some modern works, has been generally acknowledged.   All sur-
geons at the present time know that induration of the tonsils, with
tumefaction, is nothing else but an hypertrophy, and that it never, or
almost never, gives rise  to scirrhus or cancer.  The treatment which
has been applied to it has greatly varied.  Without mentioning scari-
fications, eulogized by Asclepiades, Celsus, Heister and Maurain, as
well as  by some of the moderns, and among others M. H. Berard,
  vol. in.                      7 
50
NEW ELEMENTS OF OPERATIVE SURGERY.
 (Fabre, These, No. 133, Paris,  1832,) it has been attacked also by
 cauterization, the ligature, extirpation and excision.
   A. Cauterization.—Mesue, who appears to have  been the first
 who ventured to apply caustics to the tonsils, made use of the actual
 cautery.  Brunus adopted the same practice, at least when it was his
 intention to destroy the whole  disease.   Mercatus, who followed,
 made use  of a gold cautery moderately heated, and  which he con-
 ducted through a canula.  M. A. Severin, less exacting than Merca-
 tus,  contented himself with an  iron instrument, and did not have
 recourse to it any  more than his  friend  Affisius,  except for tonsils
 with a large base.   Wiseman, after having mentioned that Ed. Mol
 very successfully cauterized the tonsils by perforating them at seve-
 ral times with a red hot iron, nevertheless confesses that he prefers
 the employment of escharotics,  which Junker, Heister and Freind
 also  advise, under various forms.  The lapis infernalis,  successfully
 employed by Morand, is also sometimes in usage at the present  day,
 but it "possesses no advantage any more than sulphate of iron, copper
 or alumine, except in cases where the induration is  recent and of but
 little extent.   MM. Perronneaux,  Roger, Sarmento,  Quotard, and
 F. Hatin, who following  MM. Bretonneau, Toirac, Guillon and my-
 self, have proposed  nitrate of silver against acute anginas, have also
devised for this purpose caustic  holders,  which might possess  some
advantage, especially that of M. Sarmento.  The red hot iron, which
 Louis seems  to  prefer,  and which should be adopted if it was pro-
posed to cauterize vigorously, is evidently applicable only to fungous
tonsils, and in cases in which we were fearful of having left behind
a portion of what we intended to have removed, and of seeing the dis-
ease repuUulate and the blood escape in too large a quantity after the
excision.  But as these different circumstances, pointed out by Percy
and  Boyer, are  but rare exceptions, it follows, even on receiving
 them as facts, that cauterization ought scarcely ever  to be resorted to.
  B. The  ligature,  devised for the  purpose of avoiding hemorrhage
with greater certainty, and giving less dread to the patient, and which
 has been  a long time employed in France,  had not, however, been
distinctly recommended by any person before the time of Guillemeau,
 who, in order to apply it, made use of a sort of knot-tightenino- for-
 ceps arranged with considerable ingenuity.   F.  de Hilden  is the
 second  author who  recommends it.  The  canula,  provided with a
 canulated  ring, and which  he invented for this purpose, in order to
 conduct and  tighten the thread,  and which instrument has been re-
 vived as a new one  by M. Smith,  (Journ. de Prog.,  etc.,  t. VI.,
 p. 275,) has not been adopted any more than the instrument of Guil-
 lemeau.  Cheselden, one of its principal partisans, applied it by means
 of a simple sound in cases where the  tumor is as it were pediculated.
 In other cases, he passed a double thread through the gland by means
of a curved needle, in order to strangulate the two halves separately.
 Sharp  operated  exclusively in this manner, which Lecat, following
 Castellanus, Levret  and Heuermann,  has  modified in this point, par-
 ticularly that from the color  of his two strands of thread, being diffe-
 rent, it is never possible to mistake them.   Bell made use of a silver
 wire or catgut; inserted it in a slightly curved canula, which he in-
 troduced to the top of the pharynx through the corresponding nasal 
POSTERIOR FAUCES.
51
fossa;  extended  its noose with the finger,  placed it around the ton-
sil, and used his canula as a knot-tightener.   Desault  was satisfied
with a Brittany thread conducted through the mouth  upon a dou-
ble erigne,  and fastened  by means of his ordinary knot-tightener.
Before him Heuermann had maintained that the polypus instruments
of Levret are those which are the best for this ligature, which, how-
ever, may be equally well applied by means of the chaplet instru-
ment of M. Mayor,  or after the manner of C. Siebold,  by means of
a  silver wire introduced with the  forceps.  The inconveniences of
the ligature, which had already been noticed by Van  Swieten and
Moscati, are so obvious to every person, and are so inherent in the
operation itself, that no one now employs it, notwithstanding the suc-
cesses  attributed to it by  Physick,  so" that it becomes difficult to
understand  the efforts made use of in England by MM. Chevallier
and C. Bell to bring it  again into repute.
   C. Extirpation, which Celsus appears to have pointed out in these
words : oportet digito  circumradere (tonsillas) et evellere, was posi-
tively recommended by Paul of Egina, ipsam totam (tonsillam) ex
fundo per scapellum resecamus, who performed it  with a curved
bistoury.   Ali-Abbas had invented for  this purpose a  sort of hook
which  is called senora, and Abu'l Kasem a small knife in the form of
a sickle.   In the place of the ankylotome of Paul, J. Fabricius advises
that we should first isolate the  gland by means of an elevator, then
seize it with the forceps and draw  upon it  adroitly in order that it
may yield without difficulty, he says, and as it were of its own accord.
It would be practicable, if it were necessary, to tear out the tonsils
by enucleating them with the nail and finger, as was probably  done
in the time of Celsus ;  bjit  this would be  unnecessarily augmenting
the sufferings of the patient, and any person  may comprehend that
such an eradication must necessarily be dangerous.   Moreover, ex-
tirpation of the tonsils is entirely useless, and excision has long since
been substituted for it.  If, however, we should decide upon perform-
ing it,  nothing would be more simple.  An  erigne, or  the forceps
of Museux, to draw and disengage the gland from between the pil-
lars of the velum palati; and a narrow and blunt-pointed bistoury to
divide  it at its root, would answer, as in ordinary excision.   Only
we must take care not to go beyond the lateral limits of the pharynx,
for then the venous plexus, or  some vessels still more important, the
carotid, for  example, which is found  on the  sides of this muscular
funnel, might become wounded, and give rise to a formidable hemor-
rhage.
  D. Excision.—Though Aetius appears to have been the first who
formally announced that we must  only remove the prominent por-
tion of the  tonsils, and never extirpate  them, excision  nevertheless
had been recommended before him.  The operation which Ascle-
piades designates under the name of homoiotome, cannot be any other
thing. Has not Celsus also described it in this phrase ? Si ne sic quidem
resolvuntur, hamulo excipere et scapello excidere.  Those who  since
then have adopted it, have almost all of them endeavored to modify
the process.  Rhazes says  that we should seize the tumor with an
erigne, and retrench the fourth part of it; but according to him, it is
an operation so dangerous that we ought rather to recur to broncho- 
52
NEW ELEMENTS  OF OPERATIVE SURGERY.
tomy.   Wiseman, instead of using the hook and ankylotome of the
ancients, or the curved bistoury and double erigne of Mesuc, com-
menced by ligating the tonsil, and afterwards made use of thetJire^ aa
an erigne, while he was excising the gland with the scissors.  Mos-
cati, who was at  first a partisan of the ligature, which  had already
been proscribed by Cavallini, and who at a subsequent period practi-
sed excision  with a  curved bistoury, fixed upon a blade of wood,
afterwards adopted another process:  he  commenced by making  a
crucial incision into the tonsil by means of a convex bistoury, after
which he excised  its  four flaps  separately, taking care to leave an
interval of three or four  days between each operation.   Maurain,
who properly censures  the method of Moscati, recommends with
Levret  that we should remove  with a single cut the entire tumor,
by means of curved scissors made expressly for the purpose.  Lecat
went back to  the double erigne of Heister, and recommended a small
concave knife with a  blunt point, or  curved and blunt scissors.  At
the same epoch Foubert recommended that we  should embrace  the
gland with a  polypus forceps, and make  strong traction upon it in
order to contuse the vessels  while we were excising  it with a single
cut of the bistoury.   Caque greatly extols the  simple erigne, then  a
blunt-pointed  knife with a cutting edge which is almost straight, and
bent into an angle upon its handle.   Louis asserts that the ordinary
bistoury will answer,  and that if we divide the gland from below up-
wards, we shall be sure to prevent it from reversing itself upon the
opening of the larynx, and exposing the patient to suffocation, as in
the cases which  gave so much alarm to  Wiseman and  Moscati.
Museux invented  for  this operation the forceps which bear his name,
and maintained that when the tonsil is once seized hold of with this
instrument, it is no longer possible for it to  escape.  Desault gave the
preference to the  ordinary double erigne, and the kiotome.  Desault's
instrument, though ingenious, is  no  longer employed.  The blunt-
pointed, straight bistoury  is  infinitely more convenient, and, as Boyer
has remarked, in every respect deserves the preference.  The reason
why authors have varied so much in the  manner  of performing so
simple  an operation,  is because, in intractable persons, children for
example, and  those whose mouth also is small and deep, or who open
it with difficulty, it is sometimes attended with considerable embar-
rassment.  A glance  at the  stages which compose  the operation will
enable me, I hope, to  reduce to their just value the principal precepts
of the surgeons who  have just been cited.
  I. Speculum  oris and depressors of the  tongue.—The first thing to
be attended to  is  to keep the mouth  of the patient open, and  to con-
trol the  movements  of the  tongue, from whence comes  the different
glossocatoches of the  ancients, and the various kinds of specula, which
followed from the time of A. Pare down to our epoch ; from whence
also comes the  chevalet, the handle of which, curved in the shape of
an S, enabled Caque"  to draw the labial commissure backwards, and
to keep the jaws  separated; and the silver plate which was applied
on the tongue, while  its handle, a little more elevated, rests upon the
lower dental  arcade,  which  it permits us to depress ; also that other
instrument more complicated, proposed by M. Lemaistre, and after-
wards  by M. Gamier, and which, without interfering with the move- 
POSTERIOR FAUCES.
53
ments of the operator, has the effect to keep the mouth firmly open
and the tongue depressed ; the plate of box-wood, or of ebony, bent at
a right angle, and in other respects quite similar to the horn, which is
used for raising up the heel of the shoe in putting it on, and which
MM.  Roche and Sanson consider very useful; from hence  comes
also the instrument of M.  Colombat, the annular wedge of M. Saint-
Yves, and  the long handle with a disc of M. A. Berard, &c.  But
a myrtle-leaf, or a spatula, the handle of a silver spoon, the finger, or
a piece of cork, are full as  good, and less embarrassing than"- those
ingenious inventions,  when  we  are  actually under the necessity of
attending to the mouth or tongue in this respect.
  II.  To secure the tonsil.—The previous ligature of Wiseman is
evidently a method more fatiguing than excision  itself.  As  to the
erigne, it is to be apprehended, it is  said,  that if it is single  it may
lacerate  the  tissues and escape ; that it  is attended with too much
difficulty to  insert  it on  the  contrary if  it is double, or especially
quadruple, as in the forceps of Museux.  It is also objected to these
last, that they interfere by their size with  the movement of the other
instruments,  and that they are not easily supported by the patient.
Finally, the erigne with three points, devised by M. Marjolin, would
be still more embarrassing if it was necessary to disengage it before the
end of the operation, than the instrument  of the surgeon of Rheims.
There can be no doubt that there is some truth  in these objections,
though most of the inconveniences pointed out are trifling.   After
all, the choice of the erigne is not here a matter of importance; pro-
vided that that which is single possesses a certain degree of solidity,
that it has an arc of a certain  extent, and  seizes  the gland behind, at
the union of its outer third with its two  inner thirds, it will  enable
 is to make traction upon it with as  much force,  and with  as little
 aceration of the tissues as a double erigne. Louis  has had no reason
•„o be dissatisfied with it, and I on my part have found it very useful
in practice.  The double erigne also, which was still used by Desault
and  Boyer, has no other inconvenience, in my opinion, than  that of
being  a little more  difficult  to  adjust.   The forceps of Museux,
though less  easy of management, but preferred by Dupuytren, pos-
sess an advantage which  is not found in the erigne of M. Marjolin ;
which is,  of not incurring the  risk when  we  withdraw  them, of
wounding the different parts  of the mouth.  The erigne-forceps of
M. Ricord have no advantage over those of M. Marjolin.  The same
may be said of the polypus forceps of the shape of an L of M. Chau-
met, those of M. Saint-Yves,  and the  erigne with four hooks of M.
Baudens.
   III. The large blunt or probe-pointed  bistouries, and which are
curved or straight, with a spring or fixed  handle, being merely a re»
production of the  ancient instruments,  are entirely unnecessary,
though they have been proposed by MM.  Blandin, Amussat,  Ricord,
Baudens, and myself.   As to  the cutting instrument, the only choice
at the present day is between  the  scissors and  the  probe-pointed
bistoury.  With the first we are more certain, especially in selecting
the  scissors  with blunt or probe points  curved on their  flat side,
 particularly  the scissors of  M. J. Cloquet, (Arch.  Gen. de Mid.,
 2e ser., t. II., p. 124,) of  removing nothing  which we wish  to pre* 
54
NEW ELEMENTS  OF OPERATIVE SURGERY.
 serve.  But the section which they make has less neatness, and they
 occupy somewhat  more  space in the pharynx and mouth than the
 bistoury.  The gland, moreover, when pressed upon between their
 branches sometimes escapes from them, and compels us to make sev-
 eral cuts before we can divide it.  In respect to the bistoury, if there
 is no longer any question except of those which  are terminated  by
 a blunt or rounded point, it  is because that with the others we might
 easily wound the posterior wall of the pharynx, and with  much facil-
 ity  also perforate its outer wall.   Caque's knife is  too large, and the
 straight and narrowest bistoury is  unquestionably the best that can
 be made use of.  If the  kiotome had not  been recommended by a
 man so celebrated as Desault, and had been represented in a less  fa-
 vorable light by M. S. Cooper, it would scarcely have deserved to be
 mentioned.
   IV.  The instruments  being once selected, it remains to know in
 what manner the excision should be performed.  In making this ex-
 cision from above downwards, as some  have recommended, it is to
 be feared that the bistoury might end by wounding  the  base of the
 tongue, and that if the gland holds  only  by a pedicle, it may escape
 and be reversed upon the larynx;  but it would then be so easy by
 passing the finger into the throat to  bring it back into the mouth and
 to complete its extraction, that this difficulty, which had like to have
 happened  to Wiseman and  Moscati, is  in  fact rarely to be appre-
 hended. Louis, who had a dread  of it, says, that by cutting from
 below upwards, there would be  no  danger of such an accident, and
 that the tongue itself would thereby be protected from any injury.
 In acknowledging the justice of this* principle, Boyer and Marjolin
 concluded nevertheless to adopt it only in part.  According to them,
 if we run no risk of wounding the tongue, it is not the same with the
 velum palati, and to avoid also this last inconvenience they follow the
 recommendation of Richter, and first incise from above downwards,
 then from below upwards, terminating at the middle part of the tu-
 mor.  I see nothing to censure in these precautions only that they are
 useless.  M.  Roux usually operates  like Louis, and has no reason to
 be dissatisfied with his process.   Up to the present time I have had
 no reason  to find fault with it;  provided we take care to make the
 tonsil sufficiently prominent by drawing it  towards us, and  by slightly
 pressing it with the flat of the instrument against the arches of the pal-
 ate, as if for the purpose of grazing its curve, we obtain  one of the
 neatest  and most rapid sections possible, without  having  in reality
 any thing to apprehend.
  a. Ordinary Process.—The patient being placed upon a chair in
 front of a window properly lighted, is to have the head steadied and
 more or less turned back by an assistant.   The surgeon placed in
 front, after  having properly shaped a piece of cork, inserts it as far
in  as possible, and adjusts it vertically between the molar teeth on
one  side, in order to keep  the  jaws apart.  Having caused  the
 tongue to be depressed should it be in the way, and the commissure
of the lips to  be drawn backwards and outwards, the tonsil is to be
secured and  firmly embraced by the erigne at its  postero-inferior
portion, with  the left  hand for the left side, and with  the rio-ht hand
for the right side.  After having drawn it  out and disengaged it from 
POSTERIOR FAUCES.
55
between the arches, he  takes in his other hand the bistoury, which
nas been wrapped in a linen band up to within ten or fifteen lines from
its point; then passes it between  the erigne and the tongue, under
the base of the gland ; turns its cutting edge upwards, and cuts on its
whole length by saw-like movements, as  if in order to make it de-
scribe the arc of a circle, which is to finish at the base of the uvula,
and in this manner separates with a single cut the entire hypertro-
phied portion of the tumor.  Withdrawing at  the same time the bis-
toury, the erigne and the excised mass, he immediately removes from
between the  jaws the cork which is fatiguing them, then makes the
patient spit out and gives  him cold water, or vinegar and water, to
rinse out his  mouth  and  to gargle.  If one of the tonsils only was
affected the operation is finished.  When both are diseased we wait
a few minutes; the  blood ceases to flow, and we proceed after the
same precepts to the excision of the other.   We may in fact not re-
move  them  until after  an interval of some  days,  should  the  pa-
tient be too much fatigued or absolutely desire it; but in general they
prefer to be  operated on at the same sitting rather than  have it re-
peated  after  an interval of time, and the pain that they experience is
in general so trivial that they can support it without any very great
dread.
  b. Process of the Author.—In tractable or reasonable persons, the
process that I follow by  preference, differs from the preceding in
these particulars:—1. I place nothing around the bistoury  or between
the teeth.  2. I require no person to depress the tongue.  3. I make
use of the  simple erigne, possessing some degree of strength, and
properly curved into  an arc or hook.   I hold  the mouth  of the  pa-
tient open, and depress his tongue with the forefinger if I find it neces-
sary.   I then immediately plunge the point of the erigne into the body
of the tonsil, from behind forwards, and from within outwards.   The
tractions I afterwards make upon  the tumor to  bring  it towards
the side of the mouth and  uvula, force the  patient to open his  jaws,
by paralyzing the contractions of the tongue.  Making use of it as
a guide to the bistoury, which I glide in flatwise, the back part first
between it and the dorsum of the tongue, the erigne enables me to
direct the instrument with certainty, and  without having any need
of seeing it as far back as to the  bottom of the pharynx, to elevate
its cutting edge when it is properly adjusted, and to terminate the
operation while the wrist is inclined outwards, in as little time and
with as little  embarrassment to the patient as possible.  It is entirely
useless to wrap up  the heel of the bistoury;  but if we should take
this precaution, it would be better to make  use of a strip of adhesive
plaster than a linen band.
  c.  Another process of the Author.—The operation  I have just de-
scribed is so  simple and easy, that I can scarcely see any reason for
simplifying it more.  To effect this object however, new instruments
have been devised, which  may possess some advantages.  In order
to improve the kiotome of Desault, Physick, M. Warren,  M. Fahne-
stock, in America, and M. Toirac in France, have each one for  the
purpose of dividing the tonsil, proposed a sort  of guillotine, which is
constructed with a ring to embrace the gland, and with  a movable
blade in the  form of a large  arrow, in those of MM. Warren and 
56
NEW ELEMENTS OF OPERATIVE SURGERY.
Toirac, and in form of a circle in that of M. Fahnestock.  The one
which I make use of, after having modified it, bears a ring near its
handle, and also a shifting and  sliding point, (pique a bascule et a
coulisse,) in order to raise up and fix the body which is to be excised.
This instrument being introduced open in the manner of a spoon to the
bottom of the mouth, serves very well to embrace the tonsil, the
summit of which is immediately transfixed by the point, which  must
be made to slide an inch backwards;  by pressing on the ring of this
point, we draw into the ring as  much as we wish of the tonsil.  We
then draw rapidly the cutting circle of the tonsillitome with one hand,
while we steady its shaft with  the other, which  terminates the ope-
ration.  This is an instrument which  should be preserved for chil-
dren, intractable persons, and those who open their mouth with dif-
ficulty, and also for surgeons who are not accustomed  to operations.
  V.  Subsequent Treatment.—If the bleeding should not immedi-
ately  cease, a solution of alum, eau de Rabel, or any other styptic
liquor should be immediately given  as a gargle, or should be applied
naked to the wound by means of a forceps, if it were necessary to
make it very active or concentrated.   In cases of imminent danger,
the actual cautery constitutes a last resource, which  must not be neg-
lected, and which  is much more efficacious than the very compli-
cated mode of compression proposed by Jourdain, or the agaric hold-
er of M. Hervez de Chegoin.  In an adult whom I operated upon in
the beginning of 1831, at the house  of Mad.  Reboul, the loss of blood
was so considerable at the  expiration of two hours, that it became
necessary to apply powdered alum immediately upon the wound.   I
have seen the same thing since in one of my patients, and in another
who had been operated upon in  the medical wards at the Hospital of
La Charite.  If some inexpert person should have opened the caro-
tid, as  Tenon  or Portal, and A. Burns, Beclard and Barclay state
that they have seen, the ligature upon the primitive trunk  alone
would still offer some chance of recovery.   A frightful hemorrhage
followed some scarifications which had been made upon  the tonsils,,
and the woman was dead when  M.  Champion came to  visit her.  In
respect to the remainder of the treatment, it consists of emollient
gargles and diluent drinks;  and  the diet of  broths  and light soups,
and afterwards food that is  somewhat more generous.  In general,
scarcely  any fever supervenes, and at the  fourth  or  fifth day the
health is in a great measure re-established.

            § II.—Abscesses and Incision of the Tonsil.

  The surgeon is sometimes called upon to lay open with the instru-
ment abscesses which form in the substance  of the tonsils, as the re-
sult of phlegmonous inflammation.  The sharp-pointed  knife of Hip-
pocrates and Celsus, the long bistoury and needle used by Leonidas,
the razor of Lanfranc, the small piece of polished wood  of Platner,
the sagitellaof Arcularius, the bird-beaked bistoury devised by Vigo,
the pharyngotome of  J. L. Petit, that of Jourdain, and the lancet of
Roger of Parma, are, when it  becomes advisable  to  perform this
small  operation, all advantageously replaced by the ordinary bistoury,
when it is required  to perform this small operation.  Pressure with 
POSTERIOR FAUCES.
57
 the finger, a stroke with the nail, or an emetic properly administered,
 also very frequently answer.  We also hold  the mouth and patient
 in the same manner as for the excision of the tonsils, and the bistou-
 ry is to be wrapped in a strip of plaster to six lines from its point be-
 fore we should undertake to plunge it into the abscess.   The laying
 open of collections which are sometimes formed in  the  substance of
 the velum  palati, in the uvula and walls of the pharynx, or even at
 the base of the  tongue, is  performed  with  the same precautions,
 and requires no other attentions.

                  § III.—Cancer of the Tonsils.

  Because cancer of the tonsils is rare, we must not therefore con-
 clude  that it is never met  with.  I have  already encountered five
 cases, all belonging to the class of encephaloid cancers.  Their situ-
 ation and their relations with the large vessels of the neck  have
 hitherto intimidated surgeons and prevented them  from  meddling
 with them.   I have however in one instance  extirpated a cancer of
 the tonsil  in 1836, at  the hospital of La Charite, and I did not find
 the operation very difficult.  The patient,  who was a countryman
 of 68 years of age, had suffered from his left  tonsil for the space  of
 two years; the tumor, which was bleeding,  and already  ulcerated
 and in a putrilaginous (putrilagineuse) state, almost completely filled
 up the pharynx, occupied a part of the nasal fossae, and crowded for-
 ward the velum palati;  suffocation was imminent.  Having laid bare
 the primitive carotid, and  passed  a thread under it, as a precaution-
 ary ligature, I secured the tumor  very far back by means of a dou-
 ble erigne, and drew it strongly  forwards  towards the median line.
 A small knife curved flatwise and with a fixed handle, then enabled
 me to lay open the  left side  of the velum and to extirpate the entire
 tumor from  below upwards,  and from within outwards.  Perceiving
 the hemorrhage was trifling, I proceeded without  stopping, and by
 another external wound, to the removal of a degenerate lymphatic
 ganglion, which lay against the pharynx in  the lower part of the pa-
 rotid region.  The  precautionary ligature became  useless, and I re-
 moved it on the following day; at first nothing unpleasant occurred,
 and the wound had become cleansed, when a diarrhea with adyna-
 mia, and symptoms of purulent infection, developed themselves  on
 the 10th day, ending in death on the 17th.  An examination of the
 parts showed that there was nothing of a cancerous  nature either on
 the inner or outer side of the pharynx, and  that all the large vessels
 had been  respected.  The wounds were in  great part cicatrized,
 and we found no appreciable lesion in  the  viscera; the large intes-
 tine alone appearing to be inflamed.  This  unfortunate termination,
nevertheless, proves that the  operation is  possible,  and that there
may be sometimes occasion for undertaking  removal of cancers of
the throat like those of other organs.

                 § IV.—7Excision of the Uvula.

  The elongation of the uvula, either  by infiltration, inflammation
 or degenerescence, was  an affection which the ancients paid much
 more attention to than the moderns, and which perhaps, merits more
  VOL.  III.                      8 
58
NEW ELEMENTS OF OPERATIVE SURGERY.
 attention than is generally accorded to it at the present day.  In
 consequence of its contact with the base of the tongue, the apex of
 the uvula produces a most unpleasant  titillation (agacement) in the
 throat, causes sometimes  symptoms which appear to be connected
 with  affections of a much more serious character, as for example,
 gastritis and phthisis, and  which might lead to the  commission of
 dangerous errors in the diagnosis, as well  as in the treatment, if the
 surgeon should be ignorant of these circumstances.   Consequently
 it is important that we should not wait too long before applying a
 remedy for  the  alterations  of the  uvula,  and  that we should not
 forget that its ablation is frequently, as  Physick and Beckern more-
 over have shown, the only means of curing certain obstinate symp-
 toms, which might lead to the supposition that there existed a serious
 malady.
   A.  Cauterization.—Its  inflammation even  when acute, should  it
 have  yet  made but little progress, very readily yields to cauteriza-
 tion with nitrate of silver.   I have  used it like  M. Toriac in many
 cases, and have had every reason to be satisfied with it.   The melange
 eulogized by Demosthenes, and the  caustics proposed by Galen, are
 at most  applicable  to  cases  of serous infiltration.   The  gold  or
 iron cauteries- made use of by Montagnana and  Arculanus, the nitric
 and sulphuric acids employed by Vigier and Nuck, are very pro-
 perly abandoned.  Nobody at the  present day would venture to
 imitate the absurd advice given by Mesue, and  afterwards revived
 by Nuck and Bass, that is to say, to make traction upon the hair  of
 the head  to such degree as to tear  the skin from the cranium, after
 having tied  them with a ribbon  near their roots, and united them
 together into a topknot.
   B. Astringents.—Sal-ammoniac and  the gall-nut according to S.
 Largus, the  green shell of walnuts according to Galen, burnt alum
 mentioned by Rhazes, and pepper or ginger still recommended by
 Purmann, are scarcely in use at the present time, except  by old
 women  and country people, who, when the uvula is down,  believe
 also that they can  raise it up by placing under it a silver tea-spoon
 heated to a  very considerable degree.
   C. The ligature applied to the  base of the uvula by means of the
 canulated ring of Castellanus, as  Pare  recommends, or by the liga-
 ture-holder of F. de Hilden and  Scultetus, or in any other manner,
 though not as dangerous as Dionis considers, is nevertheless useless,
 and excision with a cutting  instrument  is  the only means, which at
 the present day is  resorted  to for the  chronic  lesions, which have
 caused the elongation, or what is called the  falling down of the uvula.
   D.  Excision.—It is moreover  an operation which has  been per-
formed  at every epoch, and  in  quite  a  great variety  of  modes.
Hippocrates  treats of  it and  recommends that it  should be done
with address; Celsus  and Galen  followed the same process.   Paul
 had instruments expressly made for it; a  staphylagrum to hold the
organ, a staphylotome to  divide  it, and a  staphylocaustum to cau-
terize the wound.  He also  speaks of another  instrument invented
 by Serapion.  Mesue, who proscribes  the entire  removal  of the
 uvula, excised it with a gold bistoury heated at the fire, after having
secured it in the ring  of a  sheath made expressly for this purpose. 
POSTERIOR FAUCES.
59
In place of this sheath, G. de  Salicet recommends that we should
make use of a tube of elder, in which he placed the uvula in order
to divide it, either by means  of the hot iron or with the common
bistoury.   Guy de Chauliac recommends a forceps or an erigne, a
concave bistoury or scissors.   The scissors, without forceps or erigne,
answered with J. Fabricius, who  afterwards  cauterized the wound
in order to  re-excite its  vitality.  A Norwegian  peasant named
Thorbern,  devised an instrument somewhat similar to that of Mesue
and  Arnaud, that  is to say, a  species of kiotome, which is  opened
in order that the  uvula may  become secured in a circular perfora-
tion  placed near its extremity, and which it is  only necessary to
allow to shut up  of itself for  the excision to  be instantly effected.
Job-a-Meckren, who has seen the uvula extend as  far  as  the lips,
considers that we  can use nothing more convenient than the scissors
with long  blades. Thorbern's instrument, improved by Raw, and
soon after revived by Bass, under the form  of a spatula provided
with a cutting tongue, did not  prevent Fritze  from attempting still
another modification to it since.  Levret, who was also an advocate
of the ligature, has eulogized scissors with a concave cutting edge,
the same as for the tonsils and also polypus forceps.   Richter found
that  scissors with a blunt point answered the purpose very  well,
and  B. Bell had adopted a curved blunt-pointed bistoury nearly  simi-
lar to that  of Pott for hernia.   The  scissors of Percy, however, for
the excision of the uvula are those which have  been constructed with
the most ingenuity and simplicity; a prolongation of three to four lines
bent into a right angle terminates  one of their blades, and prevents
the uvula from making its escape  from them,  as soon as it has  been
secured.  The only objection  to them,  as  well  as  to most of the
inventions mentioned  above, is that  they are not indispensable, and
can  be made use of only  for this  purpose ; from whence it follows,
that  the new staphylotomes proposed by MM. Rousseau and  Ben-
natti are also useless instruments.  A slender ring-forceps with  very
long handles, and  with its beak armed with three mice-teeth, is  pref-
erable to all the others.
  E. Operative Process.—The patient is placed in the same manner
as for excision of the tonsils.   The surgeon having in his left hand a
fine erigne, or a dressing, or polypus, or the claw forceps which I have
described,  secures the uvula, inclines it  forwards and a little to the
right, and then with a straight  and  blunt-pointed scissors divides  it
with a single cut at some distance  from its base.
  F. It is  not  under the  idle  pretext of preventing it from falling
into  the larynx that we endeavor, in  the first place, to secure the
uvula, but because from its being supple and very movable it might,
without that precaution, escape from the blades  of the instrument.
Oribases, Rhazes,  Avenzoar, &c, were wrong  in saying that its
entire ablation is dangerous, and that it always alters the respiration
and voice.   S.  Braun is still further from the truth in asserting that
it constantly produces loss of speech.   The  case cited by Wedel,
and  which tends  to prove that the aliments  and  the drinks  then
ascend through the nose, is evidently only an  exception.  The ob-
servations of Scheffer, Becken, Myrrhen, and Physick, and those of
my own, satisfactorily prove that the loss of an organ like this rarely 
60
NEW ELEMENTS OF OPERATIVE SURGERY.
 produces any disturbance in the organism.  It is better even to take
 away too much  than too little, in order that we may not  be obliged
 to repeat the operation;  moreover the disengorgement which soon
 takes place, causes the uvula, whose base was more or less concealed
 in the velum of the palate,  ultimately to become much longer than
 would have been at first supposed.

                      § V.—Staphyloraphy.
   Abnormal divis!ons of the velum  palati are, as in the lips, some-
 times congenital and sometimes  acquired.   If the first are almost
 always situated  upon the median line, it is generally because the
 cavity of the vault of the palate has not filled up posteriorly, and that
 its two halves are not united at that part at the usual  period.  They
 are, however, sometimes found a little to one side,  but they have
 never yet been seen double.  The  second, (or acquired,)  which are
 ordinarily  the result of traumatic  lesions,  and more especially of
 syphilitic ulcerations, are  encountered  to the right and to the left as
 well as in the middle, and under the form of notches, the  depth  of
 which is usually limited by the border of the vault of the palate, while
 the congenital extend often to the dental arcade, and  to such degree
 as to be continuous with the simple or double harelip should the patient
 be simultaneously affected with that.
   A.  History.—Nothing  in  the ancients indicates that they  ever
 undertook to  cure  this  malorganization.   Roland, Harnemann, and
 Tenon, who have mentioned and seen it, do not speak of its treat-
 ment.   The moderns,  more  enterprising  or more skilful, have en-
 deavored  to fill  up this void, and their efforts  have been crowned
 with the most fortunate  results.   In  casting the eye  upon a fissure
 of the uvula, the idea of staphyloraphy  must have frequently pre-
 sented itself to the mind.  The trials which M. Colombe states that he
 made of it in the year 1813 on the dead body, and which he wished
 to repeat in 1815 on a patient who refused to submit  to it, have not
 been known to the public.  That of which M. Graefe  published the
 details in the Journal of Hufeland for 1817, and which he  dates at
 the end of  1816, not having succeeded, has also  passed unnoticed.
 It  is therefore to M. Roux for whom it was reserved to call atten-
 tion to this subject.  In 1819 a young physician, M. Stephenson, pre-
 sented to him  the first opportunity for this operation.  It succeeded
 to his wishes, and M. Stephenson himself  made known his cure in a
 thesis, supported at London in 1821.   In 1822, the  following year,
 M. Alcock was no less fortunate than the surgeon of Paris.  It was
 then that the rights of M. Graefe to priority were appealed to by his
 countrymen.  There is  every reason, however, to believe  that sta-
 phyloraphy  had  been practised  in former  times.  Robert,  in fact
 says in  his memoirs on various medical subjects, published in 1764:
 " A child had  the  palate cleft from the velum  to  the  incisor teeth.
 M.  Lemonnier, a very skilful dentist, endeavored and  succeeded in
 reuniting the two borders of the cleft, first inserted several points of
suture in order to keep them approximated, and afterwards abraded
them with a  cutting instrument.  An inflammation supervened, which
 terminated  in  suppuration, and was followed by the reunion of the
two lips of  the artificial wound.  The child was perfectly  cured." 
POSTERIOR FAUCES.
61
The words: child, a cleft, suture, the abrasion, the approximation, and
the cure,—all this, notwithstanding the somewhat obscure language
of Robert, scarcely permits us to doubt that his dentist must have in
reality had  recourse to staphyloraphy, and not to  the  suture of a
simple perforation of the vault of the palate.   This operation there-
fore is, in every point of view, a  discovery entirely French.  It is
one, moreover, which is so frequently required, that up  to  the pre-
sent time, 1839, M. Roux has himself performed it  nearly one hun-
dred times.   M. Jousselin of Liege has obtained two cures  and  M.
Baubien a third.  M. Caillot of Strasbourg has published a fourth,
and in  1828 M. J. Cloquet a fifth.  M. Morisseau has published a
sixth, obtained  by  him at Sable, in a young girl aged twenty years.
Bonfils  communicated another about the same time to the Society of
Practical Medicine at Paris.  MM. Smith, Hosack, Stevens and War-
ren, in  America, M. Dieffenbach  and others in Germany, and MM.
Philippart, A. Berard, (Arch. Gen. de Mid., 2e ser., t. IV.,  p. 629,)
A.  Thierry  and Baraduc, (private communication,)  in France, have
had every reason to be  satisfied with it.   I have myself been no less
fortunate  in one instance.  M. Roux performs it at  the present time
in the same manner  that he did in 1819.   In Germany, in place of
the word uranoraphy, which M. Graefe proposed, others have wished
to  substitute the terms velosynthesis, kyonoraphy,  uraniskoraphy,
&c.  MM.  Doniges, Ebel, Hruby,  Dieffenbach, Wernecke, Lesen-
berg, Schwerdt and  Krimer, have  all  endeavored to  simplify the
instrumental part of it;  and in England M. Alcock himself no longer
follows the method of M. Roux in  all its particulars.   All the stages
of the operation have been discussed, and deserve to be so.
  I. Abrasion  of  the Cleft.—Cauterization by means  of muriatic
and sulphuric acid, or caustic potash, as attempted by M. Graefe, or
with the tincture cantharides, lapis infernalis, and even the hot iron,
as proposed by MM. Ebel, Wernecke and Doniges, answer a no bet-
ter purpose  for abrading the fissure of the velum palati than that of
the lips.  Excision is indispensable in  both cases.   M. Roux,  by
means of  the dressing forceps, somewhat concave and slender, suc-
cessively seizes the two halves of the uvula or of  its division near
their free  extremity, taking care to include only a very small portion
of their border; then detaches from them,  by proceeding from below
upwards or from behind forwards, a strip of tissue a  line thick, which
he  prolongs  as  far as their angle of reunion, and  even a little be-
yond, if the bony vault  remain intact.  For  that purpose a straight
blunt-pointed and very  narrow bistoury, moved in the manner of a
small saw, appears to him preferable to the scissors, which are bent
into an angle upon their handle near  their heel, and which he at first
proposed,  and which  he even still sometimes uses to commence this
excision.  In the beginning M. Graefe, in order to carry out the in-
dication in question, made use of, first, a long forceps, curved back
laterally near their points and terminating in a double  erigne;  se-
cond, of an uranotome, which is  too complicated for me to  attempt
to describe  here.  Dr. Hruby has found  that curved scissors,  like
those of Museux,.  terminated in the form of crutches, firmly secure
the velum during  the time  of the  excision.   The forceps of  M.
Graefe.  with or without hooks,  have appeared sufficient to M. Dief- 
62
NEW ELEMENTS OF OPERATIVE  SURGERY.
fenbach, who, for  the  abrasion properly so called, has contrived a
small knife, a good idea of which would  be conveyed by a lancet
which was narrow at its heel  and mounted upon a long handle.   Fi-
nally, M.  Schwerdt  differs only from the  preceding  authors in not
having his forceps bifurcated at their extremity.
  II. Approximation.—The interrupted suture,  the only one which
in these cases  can enable us  to keep the two abraded edges in  con-
tact, are nevertheless applied  in different ways.
  a. The  needles of  M. Roux, which are  short, flat and curved, in
the manner of a hook, are nevertheless broad at their heel, upon which
as in all  other needles is placed  a large  square eye.  The liga-
ture which he threads them with is composed of four or five strands,
properly waxed and about two feet long.   His needle-holder, already
known in  the arts,  is a  sort of forceps having a groove on the inner
side of its branches,  and which are tightened or relaxed at pleasure
by means  of a ring.
  b. Those  which  M. Graefe made trial of in 1816, represent very
nearly the half of an ellipse.   They are of less breadth but greater
length than  those of M. Roux, but their eye is much more elongated
and  perforates them at the side,  as  in the ancient suture needles.
The forceps designed for inserting them is not traversed by any stem.
Two rings, which are two inches apart, and which support two late-
ral  uprights, open or shut it by gliding  towards its extremity or its
handle.  At the present time the needles of M. Graefe are almost
straight and terminated in a spear point.   He has, moreover, bent
his former needle-holder into an angle near its point, in order that when
the needles are fixed  by their border into the root which tl|e branches
of this instrument  present, they may transform it into a legitimate
hook.  Finally, M.  Graefe has dispensed with the rings  of this needle-
holder, which at the present day consists only of a jointed forceps, the
movable branch of which is vibrating as in the concealed lithotome.
  c. The  needles  of Ebel, which  are straight, sharp pointed,  and
broader in the middle than at  the heel, have, like those of M.  Roux,
a square  opening  to receive  the thread.   Those of M. Alcock are
curved into  an elongated circle, and are  almost  round.   M. Dieffen-
bach has  devised some which resemble a small punch.  They have
vio  eye, are straight or slightly concave,  hollow in their posterior
half, and  may receive a leaden wire, which their inventor prefers to
any other substance, and which they readily draw after  them.  His
needle-holder, still  more simple than that of M. Graefe, is in fact no-
thing more  than a  ring forceps, whose branches, which are a  fourth
part only  of the length of the  handles, are  bent almost  into a right
angle in front near their point.
  d. The  needle and needle-holder of M. Doniges, make but one in-
strument.   It consists  of  a long stem supported  upon a handle of
ebony, slightly bent posteriorly, and terminated in front by a needle
hook pierced near  its point and hollowed on its convexity to receive
the thread.   That of M. Lesenberg differs from it only in this,  that
it is formed of two parallel branches, which are  separated or approx-
imated by the same mechanism as the first needle-holder of M. Graefe;
in such manner that all that is required is to open it after it has perfo-
rated the parts, in order that the thread that it has conducted may 
POSTERIOR FAUCES.
63
be free, and that we may withdraw the needle without acting upon the
ligature.   M. Schwerdt, in adopting this needle, has proposed that we
should attach to it the bascule branch of the last needle-holder of M.
Graefe, in order to curtail it of the shifting rings of M. Doniges.
  e. M. de Villemur has contrived some which are altogether differ-
ent. His, while being retained in the needle-holder, are straight.  Issu-
ing from their sheath, from which a central stem enables us to expel
them,  they assume the curvature of the needles of M. Roux.   As we
push them from before backwards, they fall naturally into the pharynx,
from  whence  they are  to be withdrawn gradually by means of a
dressing  forceps.  The two  ends of  each thread being brought for-
ward  and  knotted out of the mouth, transform the ligature into a
great  circle, the noose  of which it suffices to draw by its side, to
make  its  broad portion  slide backwards  into the  pharynx, after
which we untie the knot and terminate as in the other methods.
   III.  To knot the  threads.—The ligatures being once adjusted, every
thing is not yet finished ; they are also  to be  knotted and fastened.
In France it would be  difficult to  comprehend why  for this part of
the operation it would  be necessary, as  M. Graefe  recommends, to
add other instruments to those already  mentioned : 1st,  a  small hol-
low cylinder, pierced  upon its  sides ;  2nd, a forceps bent into an
angle on its back near its handle, and hollowed out with two grooves
on  the outer surface and each side of its point; 3d, a screw,  or species
of stopper, modelled after the preceding ring ;  4th, a second forceps,
straight,  and with  a handle  like  the  ordinary caustic-holder for  the
lapis infernalis ; and 5th, a long steel stem, mounted upon a handle,
dilated and cut into a square shape at its free  extremity, where  are
situated two openings to receive the two halves of the  ligature and
to form in itself a legitimate  knot-tightener.  This display  of useless
objects is sufficient of itself to make known their inconveniences, with-
out the necessity of my particularizing them.  M. Doniges  in propos-
ing the surgeon's knot as a substitute for the instruments of M. Graefe,
a sort  of crutch, cleft at the  two ends of its transverse  piece to  re-
ceive the two ends of the thread which are to be drawn  with one
hand, while with the other we push this instrument towards the su-
ture, has doubtless forgotten that the fingers would attain this object
infinitely better.   Nor can I see what advantage in reality M. Krimer
can find in the employment of gold screws,  rather than those of iron,
like those of M. Graefe, of black threads rather than white, and those
that are oiled in preference  to those  that are waxed.  The method
of M. Roux is still more simple and more natural.  This surgeon, after
having seized and  passed the two ends of each ligature one into  the
other, makes a simple knot, which the forefingers directed to the bot-
tom of the mouth,  enable him to  tighten as  powerfully as he wishes.
An assistant immediately embraces this  knot with a ring  forceps, and
holds  it firmly, in order that it may not be relaxed, while the opera-
tor is occupied with fastening it definitively by means of a  second knot
formed in the same manner,  and outside of which we are afterwards
to divide by a cut  of the scissors, each of the superfluous portions of
the threads of the ligature.
 B. Operative Process.-Staphyloraphy, properly speaking, is not either
a difficult or a painful operation; but being long, delicate, and fatiguing, 
 64            NEW ELEMENTS OF OPERATIVE SURGERY.

 it requires much  endurance on the part of the patient, and even on
 that of the operator.  Consequently  it cannot be  performed except
 upon those who desire it, who are are fully sensible of its importance,
 and who have made up their minds to submit to it.   It rarely hap-
 pens, therefore, that it is attempted in children under the age of from
 12 to 15 years.  It exacts no precautions of regimen; only that the indi-
 viduals should in  other  respects be healthy.  Diseases of the gastro-
 pulmonary passages would especially compromise its success, from
 the cough, sneezing, and necessity of spitting, which  so  frequently
 accompany them.
  I. The  different instruments, and which are to be prepared before-
 hand, are  composed of:  1st, six flattened regular and pliant ligatures ;
 2nd, twelve needles, one threaded at each end of the ligatures ; 3d, an
 ordinary needle-holder,  or  that of M. Dieffenbach, if the needles of
 M.  Ebel, which are almost straight, should be preferred ; 4th, a good
 pair of dressing forceps, the branches of which being a little concave,
 should not touch each other exactly  when they  are  shut, except at
 their point, or better still, the  claw  forceps; 5th,  a  straight, blunt-
 pointed bistoury,  narrower than  that which is generally carried in
 the  surgeon's case, or a  very sharp-pointed and very narrow straight
 bistoury ;  6th. excision scissors, and straight scissors, for dividing the
 ligatures ;  7th, corks hollowed out into a gutter at each each extrem-
 ity, to accommodate themselves to the form of the dental arcades;
 8th, a spoon intended for depressing  the tongue in  case of necessity ;
 9th, a number of  towels, an aleze, cold  water,  a glass, basin, and
 also a small quantity of vinegar.
  II.  Situation.—The patient, provided with an  aleze, and wrapped
in a napkin and  seated with his head supported by an assistant,
should be  placed in a powerful light, as for the excision of the tonsils.
A second  assistant stands ready to hand, as may be required,  the ba-
sin  and the water as well as the instruments.
  a.  First stage.—The operator being placed in front  and on  a
chair, properly elevated, first introduces the corks between the mo-
lar  arcades on either side ; then seizes the right border of the divis-
ion, by means of a forceps, in his left hand ; directs the  needle-holder,
which has been threaded, into the pharynx with his right hand ; brings
it forwards and endeavors to make its point fall at  three or four lines
outside of and near the lower part of the fissure, in order that it may
 perforate the velum.   Seizing hold of this needle by its point with the
forceps transversely, after it has  penetrated as far as possible into
 the  mouth, he detaches  its heel at the moment  when the assistant
opens the  needle-holder, and without exercising the least movement
 upon it; he then  removes  this last instrument, takes the forceps in
 his  right hand, draws the needle entirely towards  him and brings it
out of the mouth, while it fetches the ligature after it.   The  patient
being fatigued, is  under the necessity of spitting and of reposing for an
 instant.  The jaws are  then freed of the corks by which they were
 held apart, before proceeding to do on the left side with the second
needle and the  other end  of the thread, by changing hands, what
 has already been  done on the right.   In order that they may not be
 confounded with those which are to follow, it is advisable to knot the
 free extremities of this first ligature  and to depress its noose a little 
POSTERIOR FAUCES.
65
into the bottom of the throat, in order that it may not interfere with
the application of the others.  The two extremities of it are drawn to-
wards the commissures, and brought up by the assistant on the sides
of the head.  The surgeon then places the second  and afterwards
the third  ligature, if he deems  it  necessary, with  the same precau-
tions and in the same  manner, leaving between them  nearly the same
interval.
  b. Second stage.—After having depressed, to one  or two inches,
the noose of each thread while  pushing them backward, in order not
to run the risk of dividing them with the bistoury or angular scissors
(ciseaux coudes), the  operator embraces the left lip of the cleft at the
end of the uvula;  commences  with the scissors the excision of the
thin strip which he intends to remove, and which the forceps is not to
let go of, while he continues to separate it with the bistoury as high up
as the bony vault; performs the  same manoeuvre on  the right lip
with the left hand, and returns to the use of the scissors, in order to
regularize this abrasion, if  the bistoury has not been made to act in a
uniform manner on all the points of the  abnormal division.   The
blood flows out, obstructs  the pharynx and very frequently collects
in clots about  the threads.  The patient requires to be relieved from
it, and  to  gargle and  to  remain tranquil for  some moments.   In
other respects the  most difficult part of the operation is  now com-
pleted.
  c. Third stage.—The ligatures are to be now identified and to be
arranged in order, that they may be readily found again, and then suc-
cessively knotted, commencing  with that below.  When the separa-
tion is considerable, and its coaptation appears to  be attended with
difficulty,  M. Roux detaches each of its lips from  the posterior bor-
der  of the palatine bone by a transverse incision of from four to six
lines in depth.  The two  halves of the velum being then no longer
restrained by the hard parts, yield and approach each other with an
astonishing facility.  It is the mode of preventing all dangerous trac-
tion  on the part of the threads,  and the  new wound which has been
made, afterwards spontaneously closes without necessarily giving us
any  uneasiness.   In order to remedy the  same inconvenience, M.
Dieffenbach finds that a longitudinal incision at four lines external to
and  on each side of the abnormal fissure, is infinitely preferable to
that of M. Roux, as it possesses all  its advantages without having
any  of its inconveniences; that it  also heals up  of itself, and without
interfering with the relations of the palatine vault,  admits of a very
decided elongation throughout  their whole  extent, of the flaps that
we  wish to bring together.  These two modifications are not unim-
portant, and should be adopted;  the first when a  separation of the
bones is  complicated with a fissure of the  soft parts;  the  second,
which is more common, when we have only to overcome  the resist-
ance of these  last, and the  retraction of the muscles of the palate.
  C. Subsequent Treatment.—After  the ligatures are once  knotted
the  operation  is finished;  no dressing is required ; the patient is  to
remain quiet, without  speaking, and be  careful  not to laugh, cough,
vomit, spit or sneeze, and to take only broths or light soups, until the
suture has acquired some degree of solidity.  On the  fourth day the
first thread, that is,  the middle one, may be removed ; the  second or
  VOL. III.                        9 
66
NEW ELEMENTS OF OPERATIVE  SURGERY.
highest on the day after, and the third not until the sixth day.   It is to
be understood that they are to be left one or two days longer should
the agglutination not appear to have been completed  at the ordinary
period.   It need not be  remarked also that, in order to relieve the
tissues of them, we are to confine ourselves to dividing them upon
the side of the knot, which is to be held and  then withdrawn  with
the forceps.   Nevertheless the operation quite frequently fails.  A
young girl, whom I saw at the Hotel  Dieu, was operated upon for
it five times  without  success.  Many patients of M.  Roux have
succumbed in consequence of it, and  I have  seen  a certain num-
ber that this surgeon had operated upon without any benefit.  Other
practitioners  have procured a still smaller amount of successful re-
sults than  M. Roux, so that it is not  prudent to'undertake it except
under  favorable circumstances,  and in patients, for  example, who
are in good heahh, tractable and between fifteen and fifty years of
age.
  D.  Modifications.—If reunion has  been accomplished only to-
wards the uvula, as frequently happens when the fissure is prolonged
upon the median line of the jaw, it should not  be the source of any
anxiety.  Quite  frequently the opening which  results from it disap-
pears without any other treatment, after the expiration of a greater
or less length of time, which  result moreover  is to  be promoted by
inflaming the edges  with the lapis infernalis,  as I  have  done and
seen M. Roux do, or with the nitrate" of mercury, as has  been, suc-
cessfully done by M. J. Cloquet.   After all, the patient would be rid
of his  trouble with  an  aperture only, if there were not  other re-
sources, and if palato-plasty was not at our command for an accident
of this kind.
  I.  Cauterization.—There is another method yet, which is repeated
cauterization  at  the superior  angle of  the fissure, either by  a  small
bird-beaked cautery, or  the  nitrate  of silver,  as proposed by M.
Henry de Lisieux, which method has been successfully employed by
M.  J. Cloquet, in order  to entirely dispense with, or  as a  substitute
for, staphyloraphy.
  II.  Modifications.—Process of the Author.—In place of be<nnnin«
by adjusting the  threads, I commence with rawing the borders of the
fissure ; for that purpose I seize its left free border  either with the
claw forceps or  that which I have pointed out  as the one to  be  pre-
ferred, in speaking of the  excision of the uvula, in order to cut off a
strip from it and afterwards to operate in the  same  manner on the
other side.  As the small knife of M. Dieffenbach might, if necessary.
be replaced by a keratotome or by a lancet of some length, secured
by being wrapped in a  strip of plaster, or even by a common  straight
bistoury, and which has no other inconvenience than that of incurring
the risk of  wounding the posterior wall of the pharynx, I should not
hesitate to make use of it in place of the blunt-pointed bistoury ; but
a straight, very sharp, and very narrow bistoury is much better still.
Being plunged through the velum palati from the mouth towards the
pharynx, and very near the fissure  which is to  be excised, and after-
wards conducted parallel  to this fissure, at first in front or towards
the bones or from below upwards, then towards the uvula, a strip is
readily separated from it, the extremities of which, being the last that 
POSTERIOR FAUCES.                    .6*7
are detached, evidently render the excision of the whole more cer-
tain and more easy by furnishing a double support to the instrument
up to the end of the operation.   I now wait a few minutes, and, as
soon as the blood no longer flows, I adjust the ligatures with the flex-
ible needles and needle-holder of M. Villemur,—that is to say, from
the mouth towards the pharynx, or from before backwards, as is pre-
ferred by M. Berard, (Arch. Gen. de Med., 2e serie, t. IV., p.  629.)
The rest of the  operation requires no particular directions: I suc-
ceeded in this manner, in 1837, in a young man  at the hospital of
La Charite.  M. A. Berard was  no  less fortunate in another  case.
But  in a young girl whom I operated upon in the same manner in
February, 1839, the reunion did not continue.
  III.  An instrument furnished with straight  needles, carried  from
before backwards, and which  secures the velum by embracing it,
and brings back the needles  and the thread  at the  same time through
the fissure, would simplify every step of the operation, and  has lately
been  made, at my request,  by MM. Chopiniere and Foratier, pupils
of the hospitals.   M. Beaumont, (Med.-Chir. Review,  Oct.,  1838,
p. 148;  Enc. des  Sc. Med.,. 1838, p. 119,) with  the view of  more
readily applying the suture to vesico-vaginal and recto-vaginal  fistu-
las, also makes use of a sort of needle-forceps, which enables him to
introduce and draw the thread through the staphyloraphy in one
movement.
  IV.  In a boy eleven years of age, in whom a fissure was made in
the palate by a piece of wood, M. Fristo succeeded completely by
making use of a blunt-pointed bistoury to excise the parts, and of a
long dissecting forceps, provided with a sheath, for  a needle-holder.
A small hook, mounted upon a leaden handle, answered the purpose
with M. Philipart; and  M. Smith, rejecting the  complicated appa-
ratus of M. Hosack, finds nothing more  required to  introduce all his
threads than  a hook-shaped lance, (lance a  crochet.)
  V.  M. Montain's clasp is  too  fatiguing  to  be  generally adopted.
Finally, if the fissure should continue near the incisor teeth we might,
as M. Sanson (Diday, These  de Concours, 1839, p. 25) did  in one in-
stance with success, shut it up by means of a flap borrowed from the
upper lip.
  [Staphyloraphy.—From a recent elaborate work of the celebrated
Dieffenbach,  (Die Operative  Chirurgie, Leipzig, 1845—see also^ con-
densed abrege of this work in the Dublin Journal of Medical Science,
Nov., 1845,No.LXXXIIL, vol. XXVIII., p. 227—249,) it would ap-
pear that this surgeon now dispenses with the usual  preparative pro-
cess of familiarizing  the  parts  to  the touch of the  instruments, fin-
gers, &c, before proceeding to  the  operation, from having  himself
found it impracticable, and also from patients being so averse  to it.
He however  approves of it where it  is practicable, illustrating its ef-
fects by the  fact, that those who suffer  from chronic ulcers in  the
throat, lose altogether the sensibility  of these parts by frequent gar-
gling and pencilling.   He uses short curved needles, the blunt ex-
tremities of  which are  formed  into hollow tubes for holding the
pointed ends of the  leaden  wires  used  for  the sutures.   The  leaa
wire should be of new drawn lead, as the old is brittle.  The  clots
of blood are  removed by a small piece of globular sponge, fixed in a 
 68           NEW ELEMENTS OF  OPERATIVE SURGERY.

 delicate forceps.  The patient  may take water  in the mouth after
 the margins are excised, but not gargle, as  this excoriates the abra-
 ded parts.  When the cleft is not wide, and after the clots of blood have
 been thoroughly removed, the lead  stitches, the upper one of which
 is to be inserted  first, are to be twisted close together, so as to bring
 the edges of the excised cleft into perfect and intimate contact, so
 much so that the lead rings (i. e. sutures) become  covered with the
 mucous membrane. But all this is not to be done until the whole num-
 ber of sutures have been inserted, and which are only to  be gradually
 approximated at first.  Prof. Dieffenbach makes his excisions with the
 hook and bistoury.  The side incisions through the velum, (and which
 we should say, ought to be made after excising the edges of the fissure,
 and inserting the sutures loose,) he deems of vast importance.  One is
 made on each side the  cleft, plunging the bistoury in half an inch dis-
 tant from it, and  half an inch distant also from either end of this cleft.
 The bistoury, with a sawing motion, is  then carried directly upwards
 to the bony palate.   Considerable  blood  flows, and the mouth must
 be washed frequently with cold water.   The good effect of these in-
 cisions is seen immediately, the still-strained palate hangs down lax,
 like a damp curtain, and the wounds on the sides appear like two
 oval clefts, which would admit two fingers.  The painful and strain-
 ing sensation, which penetrates into the ears, also ceases immediately,
 and the air passes freely in and out  through them.  They are espe-
 cially necessary and before finally tightening  the wires  and closing
the cleft, when the fissure is wide and ascends high up; in such cases
 the lateral incisions have to be made through the palate, as near the
 cheek as possible. The patient must  remain in bed, rather in a sit-
 ting than in a  recumbent  posture,  and  the mucus  which collects in
 large quantities about the stitches, is  to be frequently cleansed off by
 the sponge, as mentioned for removing the blood.  Only water and
 mucilaginous drinks are to be  given, as lemonade  and acids oxidize
 the wire. On the third  day the mouth may be washed with tepid wa-
 ter or elder tea, and on the fourth, the  agglutination being ascer-
 tained to be complete, by probing it with the camel's-hair pencil, the
 first ligature may be removed, and on  the fifth and  sixth days  the
 others.  Frequently, in fact in many cases, M. Dieffenbach has thus
 succeeded in uniting the entire cleft.  The shorter  the cleft, the nar-.
 rower it is, and in these, two or three stitches only will answer.  If
 the stitches cut through and the cleft opens, they are  to be speedily
 removed.  Sometimes they suppurate, leaving only one.  In that case
 they must also be removed without  delay, except that one which is left
 for the support of a bridge. At the next  operation, the  edges being by
 this bridge found more approximated, will require an abrasion of  a
 straw's width only. The preservation of union in the lower half is still
 more fortunate.   If all the stitches cut through, the  next operation
 should be deferred at least a year, as the scars will not have become
 soft till then.   Frequently, M. Dieffenbach has succeeded completely
 in his subsequent operations.  In a young lady, he met with entire
 success, though other surgeons had failed antecedently in three dif-
 ferent attempts.   The  side incisions close without any aid from art.
 If after their closure  any granulations protrude,  they are  to be
 touched with nitrate of silver.   The closing up a cleft in the hard or 
POSTERIOR FAUCES.
69
 bony palate by the distinguished professor's method, is probably more
 easily described than accomplished.  He first punches a hole through
 each edge of the cleft, and inserts a thick soft silver wire, which is to
 be drawn upon and  twisted as close as it can  be, after  having
 first cut down upon,  and then separated or cut through the palate
 bones  on each side where they join the alveolar processes, by means
 of a  thin, smooth, concave  chisel.    The  flesh wound  thus  left
 soon cicatrizes, and an advantage is  gained  as to approximation of
 the cleft, by  exciting its edges with the hot iron or tincture of cantha-
 rides,  so as to produce suppuration and granulations upon them.
   After  the  bony cleft is  sufficiently  closed,  the cleft in  the soft
 parts is to be sutured, and  the side slits are to be made as before.
 The rest of the operation consists in covering over the bony cleft with
 mucous flaps, detached from each side, and drawn over and pressed
 into the cleft, and united at their free  borders with  fine leaden su-
 tures.   The  abraded surface left by these flaps fills up with granula*
 tions, which  prevent the mucous  operculum from retracting again
 entirely, should some of its  stitches cut through.   It sometimes be-
 comes necessary to cut entirely through a sound soft palate, in order
 to reach and extirpate or to cauterize steatomatous tumors, adherent
 to the  posterior  portion and to each  side.   This cleft is to  be left
 open for free respiration till  the cure is effected, and then reunited in
 the manner already described.
   Small openings that remain in the palate after it has been stitched,
 or which come from ulcers, are found  to be more effectually  closed
 by concentrated  tincture of cantharides,  than  by nitrate of silver,
 which latter Professor  Dieffenbach says causes  the loss of a layer of
 the organized mass, while the process of granulation  which follows,
 produces  an  insufficient deposit  of fibrine, so  that the hole gene*
 rally, actually increases  in size.   This, if  accurately true, is a most
 important point to  be  remembered in all  such apertures, since it is
 well known that they have  hitherto been almost exclusively treated
 by cauterizations  with the  lapis infernalis.  If these apertures are
 large and oval, their edges are to be  regularly  excised and  brought
 together by a sufficient number of lead wire sutures.   If we endea-
 vor to cut round apertures  into oval ones, there is risk, as the open-
 ing becomes larger if we fail.  Their  edges should be abraded how-
 ever, and one or two stitches inserted, which are to be tightened after
making a crescentiform  incision through the palate on one side only
of the  hole, or if the hole is  of considerable size, we should make one
of these incisions on each  side of it.  The lateral incisions  are to
be stuffed with  lint, which causes them  to keep open, after  which
they gradually fill up  with  granulations.   Small  holes in the hard
palate  may also be healed up by excising their edges,  also by means
of tents of lint saturated  with  concentrated tincture of cantharides,
kept in for an hour at  a time and prevented from being swallowed
by a strong thread attached to the tent  and  fastened outside the
 mouth. For  large  openings the professor recommends  an artificial
 palate  to cover the same, but not to project into it, and which instru-
 ment should itself be covered on its outside with a thin layer of gum
 elastic, and fastened by means of flat  wire-beams to the cheek teeth.
 This does  not prevent attempts at a radical cure by taking out the 
70
NEiV ELEMENTS OF OPERATIVE SURGERY.
palate daily, and moistening the borders of the instrument with the
tincture of cantharides.   In  this manner he has  frequently seen aper-
tures that a finger could entei finally closed up.
  In all his operations on cleft palate", he gives the preference to lead
wire sutures, because they can all be gradually tightened to the same
degree so as  to make  uniform traction ;  whereas waxed  silk and
thread ligatures cannot be tightened uniformly, and some of the su-
tures will draw more than others and some even cut through.  The
hook and bistoury in making the excisions is far less irritating to the
palate, and more commodious, he says, than the scissors.  He says
the suture is much more difficult, if we adopt M. Roux's mode and
adjust that before making the side incisions.  The side incisions also,
even if we do not succeed, give us a better chance for success after-
wards, for nature  compels them to close up with new granulations,
which of  course in the same proportion diminishes the width of the
cleft.   M. Dieffenbach  strongly  condemns the cylinders used by
Villemur's method to introduce the needles.
  The wearing of any kind of obturator, that goes entirely through
the aperture or the bony palate, as for  example sponge or metallic
substances, must necessarily defeat its own object in a measure,
by enlarging the aperture itself.  M. Dieffenbach has  thus seen an
aperture of the  size of a quill increased  so much as  to  admit the
finger.  There is no apparatus for clefts or holes in the soft  palate,
nor imitation  velums and uvulas which can be employed  without
danger.   In small apertures of the velum with callous edges, we
may, until we operate, allow the patient  to wear a  double  elastic
plate, which represents a kind of caoutchouc stud, until it is  practi-
cable to operate.  This is the invention of M. Dieffenbach.  The
intermediate portion must be so small in diameter as not to touch
the edges.  [Quere.   Why  could not this  ingenious contrivance of
M.  Dieffenbach be used also for large apertures and wide  fissures
in the hard palate, and thus  avoid the danger of increasing their
diameter ?  T.]
  In applying  it the patient  stands before  a glass, and pinching the
inner plate with a forceps  inserts it  through the hole,  when  it is
immediately adjusted by its own  elasticity.   It is to be removed
three or four times a week  in order to cleanse it, and also to touch
the edges of the opening with the tincture of cantharides  should
there be a prospect of diminishing the aperture  by this means.
  In  children, where the cleft goes  through the entire roof of the
mouth, an apparatus  made of a steel keel  which goes over the head
and has circular plates  attached, which  constantly press on  both
cheeks at once, will,  if worn for some time, sensibly diminish  the fis-
sure by the compression it makes on the jaws.
  In conclusion, to restore a destroyed velum is next to impossible;
but in partial destruction of  one side only we may make trial of the
lateral incisions, excisions, and sutures, as  above described.   When
through scrofulous ulcers or  other affections, the posterior surface of
the velum has  become agglutinated to the  pharynx, thus completely
cutting off and isolating the  nares from the throat, closing up  the eu-
stachian tube  and causing deafness, it becomes exceedingly  difficult
to separate the parts.  This is to  be done by  a cross incision, and 
POSTERIOR FAUCES
11
then detaching the soft parts from the posterior pharynx, and aiding
this operation by a suitable spatula passed through the nose.
  Mr. Fergusson of London, (see British and Foreign Medical Re-
view, April, 1845, No. XXXVIIL, pp. 415, 416,) by dissection of the
cleft  of  the soft palate, and a careful inspection of its movements
during life, comes to these conclusions :  1, that the flaps are slightly
drawn upwards and to the sides, when the levator palati contracts ;
2, that when the levator  palati and  palato-pharyngeus act strongly
and together, the flaps are so forcibly drawn from  the  mesial gap,
that they can scarcely be distinguished from the sides of the pharynx;
3, that the flaps are  forced together, and  the edges, come into con-
tact when the  superior constrictor muscle contracts during the act
of deglutition; 4, that the circumflex palati possesses but a feeble
power over the flaps; and 5, that the fibres of the palato-glossus
were very imperfectly developed in the specimen in his possession.
  Based upon these principles, he proposes a new process, which  he
has in two instances applied with entire success.  This consists  of
the division of those muscles of the palate, which have the effect  of
drawing  the  flaps  from  each other, and widening the gap between
them when they contract, so that the stretched velum may be in a
state, of repose, and the joined edges may not be pulled asunder  by
any convulsive action of the parts during the process of union.  That
is, as an  accessory to  the operation, he advises a  division of the
levator palati  and  palato-pharyngeus  muscles, and if requisite tht
palato-glossus.  This  is intended to effect methodically,  by the ap-
plication  of  myotomy to staphyloraphy, what  probably  is more
thoroughly  attained by M. Dieffenbach's large side-incisions through
the velum.                                                .
  Our countryman. Dr. Mutter, states that by the mode in which  he
has proceeded for staphyloraphy, he has succeeded in giving relief to
all but two  cases out of the twenty-ninejie has operated upon.  (Re-
port on  the  Operations for Fissure of the  Palatine Vault.  By  T.
D. Mutter,  M.D.  1843.)   Dr. Miitter,'like Dr. Mott, has found* great
advantage in the preparative familiarization  of the parts to the instru--
ment, finger, &c.   So decided was this effect in one case, that Dr.
Mutter could dispense with all  means  for keeping the  jaws open
or the tongue in place.  He uses the  hook, and seizes the lowest
angle of one edge of the cleft first; then plunges a thin, narrow-bladed
knife into this part, and like Dieffenbach, excises  rapidly upwards to
the bone.   The strip is then drawn tense and detached downwards.
His needle  is small  and  curved, and fixed  in Physick's forceps, and
the thread  is waxed silk.  Unlike Dieffenbach, Dr. Mutter puts  the
lowest suture in first.  We have noted  the  principal points in which
the  steps of  Dr.   Mutter's  process  differs from  that  of others.
He has never met  with  any serious accidents.  If severe  griping
should follow the operation, and  which  symptom  he attributes to  the
swallowing of blood, he recommends as the best resource, injections
to be repeated every hour till the  blood is brought away, or if  re-
quisite an anodyne  enema.
   Sir Philip  Crampton's process differs from most  others in two
 peculiarities, (Dublin Journal of Med. Science, vol. XXII., 1843, p.
 320,  &c.):  1. in securing the ligatures, which  are  of the ordinary 
72
NEW ELEMENTS OF OPERATIVE SURGERY.
kind, by passing down upon them, as suggested by Mr. Maclean of
Dublin, a small metallic bead, which, when  it reaches the edges of
the cleft and  has  drawn  them together to the  degree required, is
compressed by a forceps, and thus makes a  knot unnecessary ; 2, in
discarding the starvation system of some, and  allowing the  patient
to eat all kinds of lubricating soft food, as jellies, custards, soups,
&c.   He had at  the period mentioned performed the operation by
his process in  two cases, one a boy aged 12, and also on a young
lady aged 16, in both with entire success.
  At the sitting of the Paris Royal Academy of Sciences, March 17,
1845, (see Arch. Gen. de Mid., 4e ser.. t. VII., April, 1845,  p. 507,)
the commission, composed of MM. Pariset, Roux and Velpeau,  re-
ported in the  most favorable terms of a new artificial substitute for
perforations  through the  vault of  the palate, lately invented by
M. Stevens.   This obturator is remarkable  for its  nice adaptation to
the parts, without  the  aid of springs, clasps  or hooks;  also for its
lightness, delicacy and  strength, and  the ease with which it  may be
adjusted  or  removed.   In the case to which it was  applied, a
superior officer of the army in Africa, there  was a  large opening
from  the nasal fossae into the buccal  cavity,  causing all the usual
annoyances as to  deglutition,  articulation,  &c, all of which were
perfectly removed by the apparatus.  T.]

 •
                        CHAPTER IV.

                 THE OLFACTORY  APPARATUS.

                   Article* I.—Nasal FossiE.

                     § I.—Foreign Bodies.

  A. Foreign bodies  of  all kinds  are found in  the nares.  Khern
(Planque, Bibl. Med., t. XXL, p. 568,) saw there a calculus of the size
of a pea, and which was  ejected by sneezing, after the continuance,
for a year and a half, of pains between the two eyes.  In another
case (Gaz. Salut., 1768, No. IV., p. 3,) the concretion was  almost as
large as a nut.  M. Graefe speaks of a calculus that had formed upon a
cherry as its nucleus ; also of another in a gouty person, which was
friable.  A nasal calculus mentioned by Wepfer (Jourdain, Mai. de
la Bouche, t. I., p. 519, obs. 19,) and which was an inch long, rested
upon the root of the only tooth which the patient had remaining.  It
is to  be remarked, also, that  stones  have  in  this  manner  been
very frequently ejected  from the nose.  A girl  ejected, first, seven
stones of the size of a pea, some of which were of talc  and  others of
granite; second, four other fragments of the size of a filbert and ir-
regular in shape ; third, another stone ; fourth, three more stones ; and
fifth, three small bladders, according  to the report of a curate (Gaz.
Salut., 1761, No. X., p. 3,) who was the dupe of this personage.  Two
small girls who were brought to Deschamps (TV. de la Taille, t. II., 
NASAL  FOSSAE.
73
p. 131, obs. 47)  by their mother, one seven years of age and  the
other eight, pretended to have been throwing *out stones from their
nose and ears during the space of several months ;  some of the stones
exhibited to the  surgeon left him in no doubt as to  the deception;
one was a piece  of wall plaster, the other a very small flint; the chil-
dren confessed the trick.
  B. Apea had assumed in the right nostril the appearance of a poly-
pus ; Renard (Gaz. Salut., No. 51, 1761, p. 4,) extracted it with the
tenaculum in presence of five of his confreres, who had been deceived
by it.  Dumoustier mentions two dry peas which had been  intro-
duced into  and had become swollen in the nose during the space of
two days.  It  became necessary  to  extract them in fragments, by
means of a gimlet, (Obs. et  Reflex, sur quelques  Corps etrang. etc.,
Strasb., 1810, p. 8, obs. 3.)  Meckren (Obs. Mid.  Chir., chap.  14,)
even speaks of a polypous excrescence containing within it a fragment
of wood, which  a child three years of age had  secretly thrust up
its nose, and which had been the  cause of the suppuration  and ex-
crescence.   An earwig which  got into the nose and occasioned there,
according to Sandifort, (Exercit. Acad., 1788 ; Gaz. Salut., 1786, No.
51, p. 83,) excruciating pains, was expelled during fumigation with tepid
water, and was followed by the evacuation of  a fetid pus.   A leech,
which had  been  swallowed  and become attached to the nasal fossae
in the druggist Lalouette, (Rec. de Mem. de Med.-Chir. et Pharm. Mil.,
t. X., p. 406,) kept up in this manner an epistaxis during the space
of three weeks.   Bleeding,  astringents  and topical applications had
no effect;  a tampon  of  lint, wet  with  eau de Ravel, succeeded no
better.  The blood began to flow again when it was  taken away in
the morning ;  the patient finally blew his  nose and the leech was ex-
pelled.  Thos. Etbrun (Gaz. de Med., p. 288, t. II., 1761,) also mentions
that a leech, whose head and tail had become attached to the  poste-
rior cavities of the nose, produced an epistaxis and spitting of  blood,
during the  space of from  18  to 20  days, which resisted every remedy
and  several bleedings; the inhalation  of saline  vapor through the
nose caused the leech to drop off behind the uvula, where  it  was
seized with the forceps.
  C. A cherry nut, which had caused an obstinate pain in the head,
spontaneously came out through the mouth, after having remained a
long time in the  nose.  A similar  fact is mentioned by Verduc, (Tr.
d'Oper., p. 229.)   A young lady in this manner ejected calculi of the
size and shape of dates, according to Bartholin, (Planque, Bibl. Med.,
t. XVIII., p. 97,) and of the dimensions and length of the finger, ac-
cording to  Water, (Coll.  Theses de Halter, t. II., p. 230.)   A peasant
girl had a stone in her right nostril, which shut it entirely up and occa-
sioned  an extensive tumefaction of the nose.  A fetid sanies con-
tinued to ooze out from  thence during  the space of  17 years;  and
the septum had  become  pushed towards the right.   M. Rittmeister
(Journ. d? Huff eland, 1817, et Bibl. Med., t. 62, No. 185, Decembr.)
succeeded in extracting the stone from it by means  of the forceps.
It weighed two gros and a half, and was an inch in diameter.
  D. M. Champion has  found the best  means  of extracting such
bodies to be the black pin with two branches, or the hair pin fastened
upon a cork.   I  have procured the same  success with an ordinary
   vol. m.                        10 
74
NEW ELEMENTS OF OPERATIVE  SURGERY.
probe, curved into a hook near its blunt point.  Madame D. called on
me, in great trepidation, with her child, three years of age, who  had
just introduced into its right nostril a flint which  could not be ex-
tracted.  It was a smooth stone in the form of a sugar plum, and of
the size  of a large almond.   The  small  hook readily relieved the
little girl of the difficulty.   We may in this manner remove peas and
the pits of fruit and other uniform bodies ; if the substances were
stems, or angular or adherent bodies, the forceps would be preferable.
For  living animals and insects it would  be necessary to have  re-
course to injections of various kinds of liquids.  Making the patient
sneeze and blow his nose also is an auxiliary means which he is not
to neglect.
   [Foreign  bodies—Nostril.—Dr. P. F.  Eve  of  Georgia extracted
from the right posterior nares, Tby means  of his forefinger introduced
into  the  mouth, a tailor's thimble which  a little girl  aged six years
had got up her  nose while playing with it, and where it had remained
deeply impacted  for two  weeks, without however producing  much
inconvenience,  (Amer. Journ.  of the Med. Sc,  Philad.,  1839,  vol.
XXV., p. 494.) T.]

               § II.—Hemorrhage  and Tamponing.

   Whether the bleeding which comes from the nose be the result of
a traumatic lesion or sanguineous congestion, as soon  as it yields no
longer to revulsives, cold  topical applications, styptics and astrin-
gents, or that its duration and abundance give room for anxiety, the
surgeon should  without hesitation have recourse to the tamponing of
the nasal fossae.
   A.  This operation, which is as simple as it is easy, is performed in
the following manner:  We first prepare  a roll  of lint sufficiently
large to shut up the posterior  opening  of the nostril, around  the
middle of which is tied a double waxed-thread, and to this also a long
common thread.   Other rolls, which are of smaller size or merely
made with coarse lint,  are also to be prepared  beforehand.   The
operator passes into the pharynx, through the bleeding nostril, either
a  gum elastic catheter  or catgut, a leaden or silver wire, or even a
stem  of flexible wood, or  if it  is practicable Bellocq's sound, and
proceeds  in such manner  as  to bring to the outside, through the
mouth, the extremity of one of these objects, either by seizing it at
the bottom of the throat with one or both fingers,  or by pushing the
spring of the sound, if it is this that he employs.  Then attaching the
double thread to  this extremity, he draws upon it  in order to  bring
the roll of lint  into the  posterior fauces, carrying with it the single
thread.  He  then removes the  guiding instrument, which has now
become superfluous: again draws upon the plug of lint and forcibly
secures it from  behind forwards in the diseased nostril, which is thus
found  closed up  posteriorly;  separates the two  extremities of the
ligature which  come out  through the  nose; passes between  them,
from below upwards and before backwards, the other  rolls or coarse
lint, until the front portion of the nasal cavity is entirely filled up by
them; afterwards crosses the threads as if for the  purpose of knot-
ting them, and tightens them with all the  force that he judges neces- 
NASAL FOSSAE.
75
sary upon this last mentioned  tampon, in such manner as to push it
backwards, at the same time that he acts again upon the other with
equal force in order to'bring it forwards.   By this means we may ^
easily fill up the nostril with lint, close up at least jts two openings,
and  present an  insurmountable  obstacle to the  hemorrhage.  The
two  ends of the thread which come out of the mouth and nose are to
be raised up and attached to  the cheek, or  fastened  to the night-cap
of the patient, until the period arrives when the dressing is to be re-
moved.   It is at this time only that  the single thread is to perform
its office, unless the surgeon has been forced to withdraw and to re-
place the posterior nasal  tampon before definitively adjusting it pre-
vious to removing the whole, which should never be done before the
complete cessation  of the molimen  hemorrhagicum, or seldom, at
least, before the second or third day.   He  then divides or unties the
anterior knot and withdraws  through the nose, by means of the for-
ceps, all  the  lint, with the exception of the first plug, which is re-
moved from the pharynx, by  the  mouth, by making tractions upon
the posterior thread.
   B. We are indebted to M. Martin Saint-Ange (Lapeyroux, These,
No. 314, Paris, 1836,) for a process  still more convenient than the
preceding.  A canula opening at one end into a small sac, and pro-
vided upon the side of its other extremity  with a faucet, which may
be opened  or shut at pleasure, composes the entire instrument, which
the  author denominates a rhinobion.   It is introduced, shut up, into
the  nose as far as to the pharynx.  It is then opened, and  air blown
or water injected through the canula into the little sac; it is then
shut up,  and the distended sac drawn towards us from  behind for-
wards, and the whole fastened upon a tampon of lint in front of the
nostril.   This  instrument, which Bell  and  M. Miquel-d'Amboise
(Ibid.) had mentioned, has also succeeded  upon  the patients treated
by  M.  Martin  Solon (Bull, de Therap., t. XII., p. 20,) and the in-
ventor.
   [Epistaxis.—M.  Negrier (Arch.  Gen., 4e ser., t. II., p.  354, 355)
recommends as a curative means in nasal hemorrhages, to keep the
two arms raised up above the head, while  the nostrils are to be held
shut.  He has known two persons who were in the practice of this
method, to stop a  bleeding of the nose which they were  liable to.
The curative action is ascribed by him to the retardation which is
thereby effected in the return of blood to the head.  T.]

                    § III.—Polypi of the Nose.

   Polypi of the nose may be cured by exsiccation, cauterization, the
 seton, excision, tearing them out, and the ligature ; but these different
 therapeutical methods are far from being always equally efficacious or
 deserving the same degree of confidence.
   A. Exsiccation, for example, is evidently applicable only to mucous
 polypi  taken af their commencement; it is even doubtful then if the
 results which  it procures will be very satisfactory.   Moreover, at
 the present day it is only occasionally employed, either subsequently
 to,  or as an auxiliary to the excision  or tearing  out  of the polypus,
 Notwithstanding what Aetius, Alex de Tralles and Actuanus, and a 
76
NEW ELEMENTS OF OPERATIVE SURGERY.
 multitude of ancient authors  have said of the powder of Teucrium
 marum, and the apparent success which M. Mayer states he has had
%with it, this does not, in my opinion, appear calculated to throw any
*doubt upon this judgment.   I would say the same of compression
 by means of a kind of tamponing eulogized by M.  Lamauve, (Soc.
 Med. de Montpellier, t. IV., p. 129,) after having  made trial of it in
 one instance with  success.
   B. Cauterization is  somewhat  more worthy of attention, and I
 should  not  be s irprised if the future should reverse  the unfavorable
 verdict which the  moderns have given on it.   Hippocrates, who had
 already praised it,  used the hot iron by preference.  Arsenic, and ace-
 tate and sulphate of copper, were, according to Galen, preferred by
 Philoxenes,  while Antipater and Masa also made use of vermilion of
 Sinape.  Sandarach, pimento, burnt lead, the root  of the ranunculus,
 quick-lime,  and potash,  lauded by Archigenes, S.  Largus and P. de
 Bairo, have since been replaced by butter of antimony, (which Garen-
 geot used only after he had protected the sound parts by placing a plas-
 ter between the polypus and corresponding wall of the nose,) nitrate
 of mercury, nitric  and sulphuric acids, or the nitrate of silver.   These
 different catheretics were applied te the disease by means of meches,
 tents, or rolls of lint, pieces of sheet-lead, metallic tubes, &c, in order
 to touch its prominent part  and destroy it by degrees.  Afterwards
 they substituted for these, injections of lime-water,  solutions of alum
 or vitriol, astringent or styptic decoctions ; finally, the whole array of
 desiccative medicaments ; and the history of medicine shows that many
 radical cures of polypus have in fact been obtained in this manner.
  I. Process ofJensch.—In 1827 M. Wagner published some remark-
 able cases which, if authentic, are worthy of attracting public atten-
 tion.  He succeeded in discovering the secret of a German empiric
 named Jensch, who  had acquired  in his province the reputation of
 readily  curing the  most obstinate polypi.  Having gained possession
 of this secret nostrum, which is nothing else  than a melange of sul-
 phuric acid,  butter of antimony and  nitrate  of silver, M. Wagner
 (Bull, de Fer., t. XVI.,  p. 96,) was  desirous of putting it to the test
 by following out exactly, moreover, the rules  laid down by the char-
 latan.   Now, according  to his representation, its  effects have been
 almost miraculous.  The following is the process which he gives:
 A metallic stem, in the form  of a long pin, and having a head of the
 size  of  a large pea, is  the only instrument required.  After having
 placed upon the head a  layer of caustic of greater or less thickness,
 it is directed upon the  projecting  portion of the polypus,  and this
 application is repeated  from two to five times.   The operation is
 daily renewed until the tumor falls or is destroyed.   An injection of
 alum is thrown  up an  hour before and an hour after the cauteriza-
tion.  When the principal mass is detached, we confine ourselves to
touching the remainder with lapis infernalis.   The injection  should
be continued during the  space of two months ;  and in order to restore
to the sense of smell any defect that it may have sustained, we pre-
scribe to the patient powder  of nap eta (Teucrium verum) in the form
of tobacco.   Moreover, I see no objection to making trial of this treat-
ment, at least in timid patients, or where the polypus, being found as
difficult to extract as it is to tie, is greater in its breadth than its pro- 
NASAL  FOSSAE.
77
trading part.  It would not, moreover, be the first time that ignorance
and gross charlatanism have suggested the idea of an advantageous
medication to the art of treating diseases methodically.
  II.  The actual cautery,  which naturally inspires somewhat more
confidence than the potential cautery, and which, according to the
Arabic physicians, it suffices to apply on the forehead to prevent the re-
production of polypi; which has been so warmly extolled by Roland of
Parma, who applied it to the disease through a canula; by D. Scacchi
and P. de Marchettis, who  had the courage to repeat this application
successively for twenty days ; by Purmann, who succeeded in three
instances  by means of an  iron wire heated to a red heat; and by
Richter and  Acrel, who were careful to wrap the conducting tube
in wet linen, the better to protect the surrounding  tissues, is  never-
theless at the present day almost totally abandoned.  It is only occa-
sionally that we may still have recourse to it in rare instances, as for
destroying some of the remains of the polypus which have been left
after  the  other  operations, to remedy the hemorrhage which some-
times succeeds  to  its  extraction,  or to  attack organized  (vivaces)
or malignant  polypi.  None of these cases even absolutely demand
it.  In the first case, escharotics, which are less alarming to patients,
are justly preferred to it.  Tamponing  replaces it perfectly well in
the second  case.   In  the third case, the knife,  hot iron, and other
applications, are almost equally dangerous.   The kind of polypi,
which bleeds upon the slightest touch, frequently even without being
touched, and which produce a  remarkable change  in the features of
the patient, and are accompanied with lancinating pains, do not in
fact yield  to any remedy, and form a true noli me tangere.
  III. Appreciation.—The operation, moreover, is easy, so long as
the polypus is not situated too deep within.  During the space of some
days the anterior orifice of the nose is to be dilated if the cautery is to
penetrate  through it.  A speculum  nasi afterwards enables us to as-
certain precisely the situation of the tumor.   After these preliminaries,
the surgeon takes a canula, attached at an angle at its base to a han-
dle, or to the ends of a species of forceps, unless he prefers making use
of a simple tube secured by a dressing forceps; wraps it in wet linen,
and directs it upon the polypus, which may then be burnt by means
of the reed or olive-shaped cautery heated to a white heat.  Through
the mouth, that is to say for polypi in the posterior fauces, it would,
in most cases, be impossible to use  this  means, which, even in other
instances,  is frequently followed  by intense  cephalalgia and very
severe cerebral accidents, as Sabatier has repeatedly observed.
  C.  The  seton is  a resource of another kind.  Three distinct  ob-
jects, might, if necessary, be obtained by this.
  I. The packthread arranged with knots, first proposed by Paul
or rather  by  Rhazes,  afterwards by Avicenna, and especially  by
Brunus, in order to  saw  through the polypus, is a species of seton
constructed with considerable ingenuity, but which must act, to say
the least of it, as  much on the Schneiderian membrane  as  on  the
morbid  tumor.  Nor is the silver  wire,  surrounded with a brass
wire running  round it spirally and sustained by two handles,  the
one fixed and the other immovable, as recommended by Levret, in
place of the seton of the ancients, found any longer in practice. 
78
NEW ELEMENTS OF OPERATIVE SURGERY.
  II. The idea of Le Dran was more natural.  This surgeon, by pass-
ing a hook through the nostrils, in order to seize a meche of cotton in-
troduced into the pharynx by the forefinger, or by inserting a catgut,
which he brought to the exterior through the mouth, in order to attach
this meche to it and to draw it afterwards from behind forwards into
the nasal fossa, succeeded in destroying a polypus, many of the roots
of which at first had escaped from him.  It was then easy for him to
introduce daily into the nose a roll of dry lint at  first, to remove the
foreign matters; and  in the second place rolls of lint saturated with
digestive  or catheretic ointment,  calculated  to favOr the separation
of fragments from the polypus, and  to cleanse the wound.    It was
also for this purpose  and to obtain this object that Hippocrates and
LoySeau (Observat. de Chir., &c, p. 67), and some others have also
extolled the seton.
  III. Goulard, with  the intention of simplifying the process of Le
Dran, has in reality only complicated it still more. .  The hook shaped
like the nasal fossae, which he prescribes instead of the catgut, and
the  fork,  which enabled him to introduce the seton  behind the velum
palati,  instead  of using  the  finger, are evidently less  convenient.
After all, at  the present day we introduce the seton through  the
nostrils  in the  same  way  as for tamponing its cavities.  It is a
method the advantages of which  consist in enabling  us to introduce
medicated substances  upon any point whatever of the nasal fossae.
  D. Excision appears to go back  as far as to the time of Hippocrates,
or at least to Celsus, who mentions a  species of cutting plate (spa-
tha), by which it was  practised.  Paul cut out the polypus by means
of his spathapolypica, one of the  extremities of which had attached
to it a chisel,  and tore out the rest by a polypoxista.  Abu '1  Kasem
commenced  by depressing the tumor by means  of a hook, in order
afterwards to excise it with a cutting instrument.  Others, Scacchi,
for example, operated with the simple bistoury, or,  like Hutten, with
a species of syringotome, or again after the manner of Nessi,  with a
curved and blunt-pointed bistoury.  J. Fabricius censures these in-
struments and warmly extols a kind of forceps in  the shape of a dou-
ble  cutting spoon, which M. A. Severin accuses him  of having bor-
rowed  from  Nicollini,  without  acknowledging  it;  an  instrument
which Glandorp, V. Home and Solingen have successively modified,
and which Dionis, Percy and B. Bell have considered should  not be
entirely rejected from practice.   Le Dran, Manne and Levret, who
also under some circumstances excise polypi, employed no other in-
struments than the ordinary bistoury or curved scissors.  M. Wathely,
however, has in latter times returned to the use of  the syringotome,
that is to say, of a bistoury prolonged into the beak of a sound, con-
cave on  its cutting edge and enclosed  in a  sheath, in which  it can
be readily made to glide  either towards its point  or handle.   When
the  polypus possesses  a certain degree of solidity, and approximates
very near to the exterior or to the  pharynx, there  is no doubt  that by
the  process of Abu '1 Kasem with  a bistoury, or better still, the com-
mon scissors or those that are curved flatwise, we may succeed very
frequently in removing it; and that the cutting forceps of J. Fabricius
may also attain this object in the depth of the nasal fossae, under cer-
tain circumstances.  Nevertheless excision is an uncertain  method, 
NASAL FOSSAE.
79
which almost always requires to be assisted by one of the preceding
processes if we do  not wish to see the disease  repuUulate, and one
which consequently ought not to have the preference but in certain
exceptional cases.
  E.  The tearing out of the polypus (arrachement), which has been
generally substituted for excision, is a method not less ancient and in
other respects very important.   It is doubtless from  having con-
founded  the cutting pliers with the ordinary  pliers, that the moderns
have  ascribed the  first suggestion  of it to  Pare, or rather to F.
ab Aquapendente.  It is found distinctly  mentioned in the works that
Sprengel ascribes to Thessalus and to Dracon, the son of Hippo-
crates.   There existed, even at that epoch, two modes of performing
it.  In one  there was introduced by the nose a piece of sponge firmly
tied and  fastened by four threads ;  after which,'  by means of a long
needle, they endeavored  to conduct these threads  into the posterior
fauces, and to make traction above them by means of a forked instru-
ment, and  thus tear out  the polypus.   The  other consisted in first
tying the tumor with a catgut  surrounded with  a thread, and in ex-
tracting  it  afterwards through the pharynx.   Paul  and Rhazes also
speak of this last process as one in common use.
  I. Brunus recommends that we  should remove the fleshy excres-
cence by means of a hook, and G. de Salicet had  already advised the
forceps.   Aranzi, who had contrived a kind that are very long, found
great advantage in  directing the light so that it should fall into  the
nose through a hole in the window, or  through a glass globe filled
with water.  Whatever may have been said in praise of hooks, by
Job-a-Meckren, it is nevertheless to Dionis that we are indebted for
the first circumstantial details upon the subject  of employing them
methodically.   Since adopted by almost all practitioners, they have
been modified by Sharpe, who sometimes employed such  as were
curved ;  by B. Bell, who pierced, or made an aperture through their
branches, and by Richter, who for large sized polypi invented a kind
whose branches could be adjusted separately, like those of the [uterine"1
forceps.   The straight forceps are the best wherever the situation of
the tumor allows of their application.  By making them turn upon
their axis,  we act upon the polypus with a  degree  of force which
cannot be applied with the curved forceps.   These last are reserved
for  tumors which we wish to attack through the  throat and bring out
by the mouth.  As to the shifting forceps, they possess a decided ad-
vantage, when the  mass to  be extracted is  too voluminous for  the
common  hooks to embrace it with facility in  the depth of the nasal
fossae.  Whatever, moreover, may be their dimensions or general form,
it is important that their extremities should be pierced, or concave
upon their inner side like  a spoon, and  provided with small  points,
called wolves' teeth, in order that they may have  a firmer grip.   It
is also advisable  to give them as much solidity as possible ; otherwise
we  should very often incur the risk of their bending.
  II. The  tearing out of a polypus, moreover, alter the manner of
the  ancients, has never been entirely laid aside.   Theden, for exam-
ple, first  introduced a ligature upon the pedicle of the  polypus, by
means of a forceps, which formed by their union at the point a ring
dentated  upon its convexity, and pierced with an eye at each of its 
80
NEW ELEMENTS OF OPERATIVE  SURGERY.
 free extremities ; after which he made use  of his thread to exercise
 tractions upon, and to tear out the tumor.   Although Vogel has used
 with success the forceps of Theden, M. Cooper, who, when he can,
 also tears out polypi by  means of a ligature, has nevertheless deemed
 it advisable to reject their employment, and no one at the present day
 would venture to maintain that they are indispensable.  In admitting
 that this kind of extraction may have, as M. Cooper alleges, the advan-
 tage of incurring less  risk of  hemorrhage, and of removing at  the
 same time the entire root of the polypus, and the  fibro-mucous mem-
 brane which has given origin  to it, it would nevertheless possess the
 serious inconvenience of exacting two operations in place of one, of
 being applicable  only to hard, pediculated polypi, and of not being
 susceptible of  application  but with  difficulty in the depth of  the
 nostrils.
   III.  When the tumor does not exceed  the  size of  a nut, and  that
 it is solid, and without a pedicle of too great a thickness, Alorand
 has been indebted for some successful  results to the following pro-
 cess :—The two forefingers are introduced into the nose, one in front,
 the other behind, and as  far as the polypus, upon which traction is
 then made by pushing it alternately towards the  pharynx and the
 face, in order that it may be finally detached and forced  to come out
 by the passage which  presents to it the least degree of resistance.
 This is a process, moreover, which, after  the manner of  Dupuytren,
 it would  be  advisable to combine  with the employment  of hooks.
 There can be  no doubt, in fact, that by pressing with the finger
 through  the pharyngeal  opening of the nasal fossa upon the tumor,
 we should be able to effect its extraction with more  certainty and
 facility by means of the  forceps, which draw upon it in the opposite
 direction.
   IV.  Operative Process.—This mode by arrachement  requires no
 preparation, unless we should think  proper  to imitate G. de Salicet,
 by gradually enlarging the anterior opening of the nares by means of
 a sponge, or any other dilating means.  Cold water, oxycrat, one or
 more basins, an aleze and napkins, lint, and all the articles necessary
 for tamponing the nasal fossre, an erigne, scissors, a blunt-pointed and
 ordinary bistoury, dressing forceps, the  forceps of Museux and seve-
 ral pairs of polypus forceps, as they may  be required, should be ar-
 ranged upon  a table  or a broad board.   It is also advisable to have
 several  rolls  of lint sprinkled with colophane, and even one or two
 cauteries in case of obstinate hemorrhage.
   a. The patient with  an aleze around him, and seated in front of a
 window  with his head supported by an  assistant, should  have his
 hands free if he is an adult, in  order  that he may be enabled to  use
the gargle at pleasure ; or his  hands  should be surrounded  and  cov-
ered by the aleze, on the contrary,  if he is  a  child.  The  operator
being placed  in front, and standing up, introduces his hooks through
the orifice of the  nose; recognizes with this instrument  the precise
seat of the polypus, which he seizes as near as possible to the pedicle,
while taking care also  to  embrace it to a very great extent; draws it
gently towards him ; seizes it a little higher up, if it elongates, with a
second forceps, without abandoning the first; then with a third,  if he 
NASAL  FOSS.<E.
81
is still fearful of tearing it without removing it by the root, and thus
endeavors to extract it entire at the first operation.
   b. When the tumor, from being situated too far within, or not suf-
ficiently distensible to enable us to bring it to the exterior without
having lacerated it, it is more advisable, as soon as we have  seized
hold of it, to turn the forceps upon itself two  or three times without
oscillating it, while at the same time we draw upon it until the poly-
pus yields and is detached.  During these efforts the instrument is
held by means  of its rings with the  right hand, and near its entablure
with the left, in order that we may direct its movements better, make
it act in certain cases in the manner of a lever of the first  kind, and
to incline  its spoon-shaped grip with all  the force  necessary, up-
wards, inwards, or outwards.
   c. If the whole of the tumor is not extirpated at first, or if there
are several of them, we immediately recommence, and always in the
same manner, until we are certain that there is no longer any foreign
body in the  nasal fossa.  In  this respect, when we are desirous of
knowing the exact condition  of things, and that the eye no longer
affords us any assistance, it suffices to  make the patient  blow out
with force while we hold the sound  nostril shut.  So long as the air
finds  difficulty in passing we may be satisfied  that some portions
of the polypus  have  escaped the action of the instruments.   If on
the contrary nothing interrupts it, and  it comes in freely to the
respiratory passages with a clear  and full (nette et franc) sound,
it is useless  to make any further  researches and the operation  is
terminated.
   V.  Appreciation.—Mucous polypi are too  soft and adapt  them-
selves  too readily to the parts which surround them, for the narrow-
ness of the nasal opening to interfere seriously with their extrac-
tion.   With  hard  polypi it  is different; the  irregularities  which
they are covered with in order to adapt themselves to the form of the
passages, the  prolongations that they sometimes send off, either back-
wards  or forwards or into the maxillary sinus, or, as  I have seen  in
one instance, into the zygomatic fossa through the spheno-palatine
foramina, two other instances of which have also been seen, one by M.
Blandin and one by M. Cazenave, (Bull. Med. de Bordeaux, p. 25,) ren-
der it in certain circumstances extremely difficult to draw them to the
exterior.  Inasmuch  as the bones in the body of the nostrils do not
present any great degree of resistance to them, they depress  them,
push the septum in one direction, separate the turbinated and ethmoid
bones  in another,  and very  easily depress the vault of the palate;
while posteriorly the pterygoid process, the body of the sphenoid and
the thick border of the vomer  present  a  much more considerable
resistance to them, while in front the ascending process of the maxil-
lary bone  also  presents an obstacle to  them for a greater or less
length  of time.
  a. They are especially arrested by the circle or fibro-cartilaginous
border of the facial opening of the  nostril.  Owing to its great elas-
ticity and its want of distensibility this circle has a constant  tendency
to return to its  natural limits, and makes infinitely greater resistance
than the bones to the force directed  upon it.  If then it should appear
that the extraction of a polypus of somewhat large dimensions would
   VOL. III.                       11 
82
NEW ELEMENTS  OF OPERATIVE SURGERY.
 be thereby rendered too difficult, we ought, rather than  have re-
 course to the dilatation of G. de Salicet, to slit up the ala of the nose
 from its free border as high as  to the triangular cartilage, as Dupuy-
 tren recommends, as I myself have done in two instances, and as M.
 Serre (Compt.  Rend, de la Clin,  de  Montpellier, 1837)  has  also
 practised with success.
   b.  When the tumor extends  beyond the posterior opening of the
 nasal fossa, it is  rarely practicable to extract it entire through the
 nose.  *It is under such circumstances that the curved hooks become
 indispensable for seizing it  through the pharynx, as has been done
 also byM. Bermond  (Bull. Med. du  Midi; Gaz. Mid., 1838, p.
 442) with success.  If in this position it should have acquired a great
 volume, or if in consequence of any particular arrangement it had
 crowded downwards and forwards the posterior half of the palatine
 vault to so great a degree as to contract the arches of the palate, the
 method of Maune or of Nessi, indicated by Hippocrates, Guy de
 Chauliac or  Garengeot, adopted in  practice by Loyseau, (Obs. de
 Med. et de Chir.,  p. 66,) Petit  and Hulterus, (Percy, Mim. sur les
 Ciseaux, p. 70,) and which consists in slitting open from above down-
 wards the velum palati with a curved bistoury, would  not be un-
 worthy of adoption.  Heuermann and Morand had every reason to
 be satisfied with it; and I myself have tested its value in a similar
 case.   The objections  that Schumacher makes to it prove only that
 it  was not indispensable in  the  case he mentions.  It  is literally a
 debridement which is effected without any fear of wounding an artery
 of any dimensions.  The reunion afterwards took place spontaneously
 in one of the patients upon whom I operated.  The polypus, which
 may be then embraced and torn out, if not entire, at least in fragments,
 by means of the forceps or fingers, might also be excised with the
 curved scissors or  the cutting hooks of M.  A.  Severin.
   c. Finally, there are cases where it is necessary that these different
 operations should be united and skilfully combined, where after hav-
 ing extracted a large portion  of the  tumor  through the nose, and
 another through the pharynx, as  is seen in the example that M. Chau-
 met has given, whether we have detached it or not in front or be-
 hind, enough still remains to which the process  by ebraulement of
 Morand might also become applicable.
   d. In whatever manner it is performed, the patient should be per-
 mitted from time to time to wash out his mouth and nose by furnish-
 ing to him  simple  cold  water  or vinegar and water.   Should the
 hemorrhage become too abundant, every manipulation should cease,
 and further  attempts put off to  an interval of some days.  When
 however it does not cease spontaneously, it is arrested by tamponing,
 which renders the application of caustics or hot  iron almost always
unnecessary.   Nor should we  proceed  so far as this even until we
have unavailingly made use  of inhalations of the  eau de Rabel, or a
 solution of alum or some other styptic.
   VI.  Torsion.—The extraction of polypi, and especially  of mucous
polypi, is almost always effected by torsion.  The surgeon havin»
embraced the tumor well and properly adjusted the hook or forceps^
turns it while drawing upon it as if upon its axis, and thus incurs less 
NASAL  FOSSAE.                       83
risk of having the instrument relax its hold, and the polypus crushed
and broken into fragments before yielding at its root.
  VII.  Subsequent Treatment.—The tearing out of polypi is rarely
followed by  serious accidents.   It  is rare that  any  fever  super-
venes, or that the patients  are under the necessity of restricting
themselves to diet during  the space of two or three days.  It is, ne-
vertheless, a  method which is far from always succeeding, or of be-
ing susceptible  of employment under all circumstances without in-
convenience.  It is  particularly well adapted to mucous and fibrous
polypi, which have one root only, and to all those whose base is not
extended over too large a surface, or which, in a word, it is practica-
ble to extract entire.   The sarcomatous polypi, whose cancerous de-
generation commences at the projecting part, would also  be ap-
plicable  to it if, as Dupuytren alleges, we could distinguish them
from  the others before proceeding to the operation ; but according
to Boyer, it would in other cases only hasten  the development of the
accidents, and lead to dangerous transformations.   Here also, more
than in any other cases, the operator ought to recollect the anatomi-
cal arrangement of the nasal cavities, in order that he may not pinch
up  and tear out for polypi the turbinated bones which are  external
to it, nor shatter the septum which is on its inside, nor the cribriform
plate  of  the ethmoid which is above, nor mistake a simple engorge-
ment of the mucous membrane, or  some deviation  in the bones, for
an  abnormal  production, nor  fail  at any stage of the operation in al-
ways guiding the forceps in a proper direction, nor be ignorant also
that there may exist in the nose  tumors, whose root  is in the frontal
sinuses, as in the patient operated  on  by M. Hoffman, or  in the
maxillary sinus, in the interior even of the cranium,  or in the ptery-
go-maxillary  fossa for example, as in the  patient mentioned  by M.
del Graeco, and in  whom the  supra-maxillary nerve was transformed
into five  enormous masses of a polypoid appearance.   In a patient of
M.  Janson, (Compt. Rend, de VHotel Dieu de Lyon, p. 64, 1822,) the
polypus, which occupied the two nares and the maxillary sinus, made
its appearance in the mouth through an opening in the dental arcade,
partially issued through the ulcerated lachrymal sac, projected into
the orbitar cavity, from  whence it  had  thrust out the globe of the
eye upon the  cheek, and obstructed the pharynx to such degree that
it became  immediately necessary to  separate certain  portions of it
by means of  the ligature and knife in order to prevent suffocation.
In a boy 16 years of age in whom I had removed one lobe of it, and
who died of small-pox, the polypus protruded at the same time out-
side of the nose, into the pharynx, into  the cheek through the sinus
maxillare, into the orbit and temporal fossa, and also into the cranium,
the base  of which had become softened and worn away by it.
  F. Ligature.—The ligature, like most  of the preceding methods,
goes back to the remotest antiquity.   The Greeks and Arabs, never-
theless, rarely proposed it, except as  an auxiliary to excision  or ar-
rachement.   We have to come  down as  far as  to the 16th  and
17th centuries before we find it clearly described  and formally indi-
cated.  Fallopius applied it  by means of a brass-wire, a noose of
which he directed around  the polypus by means of  a silver canula.
F. de Hilden has  not described his process.   Glandorp, who  paid 
 84           NEW ELEMENTS OF OPERATIVE  SURGERY.

 particular attention to it, applied the ligature by means of a kind  of
 needle shaped like a hook, and  having an eye near its point, which
 was furnished with a silk thread.  It  was in the course of the last
 century especially, that it became  the subject of a multitude of  in-
 vestigations and modifications.
   1.  First process of Levret.—Thus  Levret proposes to conduct a
 silver wire by means of a sound upon  the root of the tumor, to make
 its two extremities afterwards pass through a double canula, in order
 to twist them by turning it on its ax.s, after having fastened them to
 the rings  which it has on its free extremity.  Pallucci, in place of
 two tubes, soldered together at  their sides in form of a double sound,
 states that he  had invented a  simple  canula like that of Fallopius,
 but which was  divided into two portions  near its nasal extremity, by
 a  small septum.   Levret himself made use of this instrument, and
 published an  account of it before Pallucci spoke of it.  It is neither
 perceptibly more or less convenient than the preceding, of which it
 is  to be considered as a simple modification.   The same  may be
 said of the instruments of Nessi, Hunter  and Kluge.
   II. Second Process.—Levret not being  enabled to reach polypi
 in the posterior nares with  his  double canula,  contrived  for this
 purpose a species  of ring-forceps  or  ligature-holding forceps,  with
 long branches slightly curved, dilated at their extremity, and hollowed
 out, but which surgeons have not adopted any  more than they have
 those of Theden, which undoubtedly suggested  them.
   III. Process  of Brasdor.—The difficult point in the first process
 of Levret, is  to secure the polypus in  the middle of the noose, which
 the metallic tube conducts to it.  Brasdor  proposed to remedy this
 inconvenience by making use of a Coupelle  silver wire doubled so as
 to form a  noose, drawn in the same way that plugs of lint are from
 behind forward, when we wish  to tampone the nasal fossae.  When
 the two  extremities of  this ligature are once  brought out through
 the nose, the  surgeon seizes them with one hand, draws thern gently
 towards him, while with  two fingers  of  the other hand  introduced
 into the  pharynx, he endeavors to pass its noose  upon the root of
 the polypus, then introduces them  into a knot-tightener,  and imme-
 diately proceeds to the strangulation of the tumor.   A simple thread
 is  moreover fixed  upon the middle portion of the  silver wire, and
 left free in the  mouth, in order to be enabled to draw the ligature
 backwards, and to replace it should it not be  found at  first to be
 properly adjusted.  This, it must  be  confessed, is a  real improve-
 ment ; but as we cannot tighten the metallic ligatures but by twisting
 them upon themselves, and  as  they consequently frequently break
 before having cut  through  the  pedicle of the  tumor, many  persons
 have always preferred to these the use of ligatures of hemp, flax or silk.
 The only advantage, moreover, which can  be  claimed for them  is
 that they form a noose, which easily keeps itself open without bending,
 and which consequently is  better calculated than  that of scft liga-
tures to glide upon the root of the polypus.
  IV. Process of Desault.—Desault, reasoning upon this hypothesis,
 at  first confined himself to adjusting a ligature of thread in place of
 the silver  wire used by Brasdor.  Subsequently, in order  to obviate
 the difficulty of forcing the tumor to become embraced in the noose 
NASAL  FOSS.E
85
of a ligature so pliant, he adopted another course.   His last process
is performed by means of three distinct instruments:  first, a canula,
slightly curved, terminated in a dilatation, (en larme,) and having a
lateral ring at its other extremity; secondly, a stem of iron or steel,
which is  a sort of knot-holder, which is shut up,  and which  glides
without difficulty into a second canula, and when  it  is open  repre-
sents a forceps, while when shut its  beak forms a true ring; third, a
knot-tightener, which is another metallic stem, one of  the extremities
of which, bent at a right  angle upon its axis, has upon it a rounded
opening, and the other of which forms a cleft plate.  One  of the
extremities of the thread is attached  to the ring of" the canula,  which
it also has passed through.  The other is then passed into the ring
of the ligature-holding forceps, which is  immediately shut  up  by
drawing it into its sheath.   The surgeon then directs these two  in-
struments  together upon  the polypus, and even  a little  beyond it,
endeavors to apply them  above or below, or to the right or to the
left of the pedicle of the  tumor, seizes the knot-holder with the left
hand and  stops it at this point, while with the other hand he causes the
canula to  pass around the whole  circumference of the polypus, and
brings it to the point diametrically opposite, in order to embrace the
pedicle accurately; glides once or twice, one around the other, the
canula and the knot-holder, in  order to transform the noose  of the
thread into a true circle; withdraws these instruments;  leaves the
ligature in its place;  passes its extremities into the ring of the knot-
tightener, which he pushes backwards with more or less force, with
the view of strangulating the morbid mass ;  fastens the extremity of
the ligature upon the cleft plate, and proceeds to attach it to the cap
of the patient, in order  to  maintain the whole in the nasal  fossae.
The constriction is afterwards augmented gradually by drawing each
time with  greater force upon  the knot-tightener,  and in the space
of a few days the section of the polypus is completed.
  V.  Another process of Desault, less embarrassing than  the prece-
ding, is that which consists in introducing the noose of a long thread
into the pharynx through the nostril by means of a  gum elastic sound
or bougie.  The operator proceeds to seize hold of this noose with the
finger as soon as it appears above the  velum palati; brings it to the ex-
terior through the mouth; detaches trom it the guiding sound,  which
he withdraws through the nose ; fixes to it an ordinary thread intended
for the same uses as in the process of Brasdor; makes fc ascend into
the posterior fauces in supporting it with two fingers, while an aid draws
its two extremities, which have  remained free, to the anterior opening
of the nose ; after which they are introduced into the knot-tightener hi
the manner described above.  If the  fingers were not sufficiently long
to follow the noose of the ligature as far as the posterior opening of
the nares,  two threads in place  of one attached to this ligature, at an
interval of an inch apart, and each of them afterwards passed into a
canula could be advantageously substituted.
  VI.—This process was  still  further modified by Desault himself}
with the view especially of more readily applying it to polypi of the
pharynx.   After having brought from the mouth and throat outside
of the nasal fossae, the extremity of one ligature, and  the two ends
of a noose of thread of a different color, he introduced into  his canula, 
86
NEW ELEMENTS OF OPERATIVE SURGERY.
which is slightly curved, the extremity of the ligature which was
left in the mouth ;  penetrated with this canula to the bottom  of the
pharynx; made use of it to pass the thread around the polypus ;
then caused to be passed upon it  the nx>se of the accessory thread,
which an assistant is afterwards  directed to draw through the  nos-
tril, and whose object is to bring  through this passage, after the man-
ner of a hook, the  second head of the  ligature, which is immediately
introduced as well as the first, through the ordinary knot-tightener.
  VII.—Boyer,  who approves  of these different methods, and has
made trial of the greater part of them  with success,  has nevertheless
found it advantageous, under many circumstances, to substitute a
catgut, to the cord of thread recommended by Desault.
  VIII.—A. Dubois, (P. Dubois,  These, Paris, 1821,) with a view of
preventing the  noose of the ligature from  becoming effaced  before
having arrived upon the root of  the polypus, recommended to  hold
it enclosed up to that point in a piece of elastic sound, of about three
inches long, which was afterwards drawn to the outside through the
nose  by means  of tractions  so  applied, as if we  intended  to  turn
this ligature  upon a pulley, while acting  temporarily upon  one of
its extremities only.  The sound  having  been removed, we draw
upon the other end of the ligature, in order to bring them out upon
the same line, and insert both into a knot-tightener.  Unfortunately
this piece of the sound does not  always follow the direction we
would wish to give to it  It slips and escapes, sometimes to one side,
sometimes to the other, and frequently does more harm than good;
so that contrivances still continue to be devised for holding  the lig-
ature  open  in a proper  manner until it reaches to the top of the
pharynx.
  IX. Process of M. Rigaud.—In the month of January, 1829, two
new instruments were proposed for this purpose.   One which its in-
ventor, M.  Rigaud, calls a polypodome is composed of three stems
of steel  susceptible  of  being moved, advanced, and withdrawn  sep-
arately or together in a strong canula.   Being curved into an arc at
their  extremity,  they form  a kind of forceps, with  three branches,
which are opened or shut at pleasure.  Each one has a bird's-eye at
its extremity;  the middle portion of the ligature is passed into these
openings, and its extremities are immediately brought through the nose
by means of Bellocq's sound.   The forceps with its three branches
approximated, are then conducted into the posterior fauces.   In that
part they are separated to a greater or less degree, according  as  it
becomes requisite to give to the noose more or less considerable ex-
tent.  Afterwards  their summit is elevated in the same manner as if
we  were  using  the polypus  forceps.   In  order to disengage  the
thread, it suffices to draw with a certain degree of force upon the
extremities which hang out of the  nose.  The two  halves  of their
terminal cleft, being sufficiently elastic to retain the noose, which is
in no  way drawn  upon, allow it to escape immediately upon the
pedicle  of  the tumor.   The  rest  of the process has nothing par-
ticular.
  X. The other, which is that of M. Felix Hatin, (Mim. sur de Nouv.
lustrum., SfC, et supp., 1830,) is a plate of polished metal  curved
near its  pharyngeal extremity ; being dilated and rounded upon its 
NASAL  FOSS.E.
87
convex surface, it may serve two  purposes or fulfil two indications.
In fact, its horizontal portion depresses the tongue exceedingly well,
while the other obliges the ligature to glide upon it until it meets the
polypus.   It is an instrument of very simple construction, which its in-
ventor uses with success, and which I myself have made trial of in two
instances ; but which could, if necessary, be replaced by a tea-spoon
bent forwards towards the root of its handle.  The polypodome of M.
Rigaud occupies less space, conceals the parts less, and is better cal-
culated to conduct the ligature where, and as  we wish, and could in
fact conduct it advantageously without passing through the mouth,
upon certain polypi in the anterior portion of the  nasal fossas, but it
has but little solidity, and is more inconvenient than I had at first con-
sidered it.
   XI. The knot-tightener itself has attracted  the attention of a great
number of practitioners.   Bichat recommends that it should be joint-
ed (brise) in order that we may, if necessary,  give it a greater or less
degree of length, without displacing it.  That of M. Graefe, which is
composed of two pieces,  one of which is made to slide upon the other,
enables us to strangulate the polypus with force, without disturbing
the extremity of the threads.  But the most ingenious of all is the one
which Roderick succeeded in constructing to  cure himself of a poly-
pus which had resisted all the efforts of the surgeons of Brussels.
(See Ligature en masse.)  The  chaplet, which it makes, perfectly
accommodates itself to the curvatures of the nasal fossae, and fatigues
them incomparably less  by its presence than any other.  Its  balls
may be made of wood, bone, or metal, and M.  Sauter constructs them
out of the point of  the horn of ruminating animals.   M. Mayor re-
commends that they should be made of silver, tin, &c. ; finally, in
place of a winch, M. Bouchet makes use of a small barrel, while M.
Levanier (Arch. Gen. de Med.,  t.  II., p. 467,) confines himself  to a
simple clapper (cliquet.)   M. Braun has also  deemed it necessary to
modify this instrument, which had already been suggested by Girault
or Riolan.
  XII. Appreciation.—The process  described by Dionis, and which
is intended for the adjustment upon the pedicle of the tumor by means
of a crow-beaked forceps of a running knot, one of the  extremities of
which is  afterwards made to pass through the nostril by means  of a
Iong«needle of lead or brass, in  order to bring it  out through the
mouth, while the other remains at the extremity of the nose, is scarce-
ly ever applicable.  That of Glandorp, as modified by Gorter, after-
wards revived by Heister, who, in order to adjust his ligature, success-
fully employed, on  a woman 70 years of age, a curved  needle mount-
ed upon a handle, pierced with an eye near  its point, and which is
quite similar in every respect, moreover, to the needle invented by
Goulard,  in order to tie  the intercostal artery, cannot however be
reasonably made trial of  except in those cases where the polypus has
approached very near the opening  of the nose.  As the anterior na-
sal opening descends below the palatine  wall of the nares, the  liga-
ture  necessarily acts with force against the facial  border of this wall,
when we draw upon it through the nose, and  tends constantly to cut
into it, or at least to excoriate it.  It was to  remedy this defect that
Levret proposed to add a sleeve  to the two ends of the seton, which
t 
88
NEW ELEMENTS OF OPERATIVE  SURGERY
he sometimes recommended to be used.  It was for the same object
that M. F6lix Hatin recommended* a small  plate, which was to be
kept vertically behind the lobule of the nose, where it was to fulfil the
office of a pulley, but which plate could be perfectly well replaced by
a steel stem pierced with an eye for the passage of the  thread.   Fi-
nally, the ligature is not adapted to polypi with a large base, nor to
those that  are vesicular.   In  whatever manner it  may have been
applied, it is necessary to tighten it daily up to the time of the separa-
tion of the  body which it embraces.  It is no  longer applied at the
present time as formerly, with the simple object of rendering the ex-
cision or tearing out of the polypus more easy or less dangerous, or
with the intention of protecting us against hemorrhage.   But  it is
with the professed intention of producing mortification of the poly-
pus by intercepting the passage of the fluids through its pedicle, which
result moreover  it effects by ultimately cutting  completely through
it.  Consequently we should be prepared to find that the tumor hag
become engorged immediately after the operation, then shrunk or
decomposed,  and requiring the employment of the  forceps or some
kind of  hook when its root has  been divided.   On the other hand,
injections of  vinegar and  water,  alum  water, or any styptic or
antiseptic solution whatever, are  in such cases auxiliaries not to be
neglected.  Prudence also  suggests that  the  patient should be con-
stantly kept with his head inclined forward, in order that the putrid
matters may not descend into the digestive passages.  Should  the
polypus moreover be about to fall into  the  pharynx, it would be
important to  introduce into it beforehand a  thread  by means of a
needle.   Otherwise,  it might pass towards the opening of the larynx
in becoming detached, and  give rise to  the apprehension of suffoca-
tion.  After this separation, it  is well to continue still for the space
of a week or two the detergent,  astringent, or styptic  injections, so
long in fact as the nostril  shall  not  have  entirely ceased to suppu-
rate.  Having pointed out while  speaking of these different methods,
the merits of each one of them in particular, it would be deemed, I
presume, altogether unnecessary to compare  them here in  their en-
semble in order to appreciate their relative value.  As there is no
one of them which can claim the preference in an absolute  manner,
it must be to the judgment of the surgeon that the choice is to be left,
of the process  which is  best adapted for employment  in each case
considered  separately.
  XIII. Polypi of the Velum Palati.—It may happen  that vegeta-
tions, small polypi and pediculated tumors, will  develop themselves
upon the nasal surface of the free border of the velum palati.   This
is a disease of which I have seen three instances.  There would be
no objection to treating it by the ligature or arrachement; but excis-
ion  would  be evidently better adapted to it.   Securing the tumor
with one hand by means of an  erigne or claw forceps, the surgeon
excises it with the other with a strong pair of scissors or straight bis-
toury.  The two patients whom I operated upon in this manner found
themselves cured on the following day.
  [Calculi in the Nasal Fossa.—Case of an  Osseo-calculous or
Bony circular Plate in the Diaphragm.—We avail ourselves here,
chiefly of a very learned and complete paper on  calculi in the nasal 
NASAL  FOSSiE.
89
 fossae, by M. Demarquay, in the Archives Generates  of Paris (4e
 ser.,  t. VIII., Juin, 1845, p. 174 et seq.)   Though this subject has
 been long neglected, cases of this description of calculi have  been
 noticed by J. M.  de Gardi, (Pratica, Venise, 1502, post 2, cap. 14,
 p. 308,) Thos. Bartholin,  (Histor. Anat. Rara, centur. 1, hist. 13, p.
 47,1654,  et Histor. cent. 4, p. 404, histona 85,) Clauder, (Ephemer.
 Curios., dec.  2, an. 13, obs. 78, an. 1685,) Kern, (Observ., 46, dec. 3,
 an. 5 and 6;  Ephem.  Cur. Nat., p.  100, an.  1700,) Vitus Reidlinus,
 (Ephem., dec. 3, an. 9 and  10, obs. 145, p. 268, an. 1706,) Wepfer,
 (Observ., 192, p. 905, an. 1727,^Ruysch, (Obs.  Anat.,  Amsterdam,
 obs. 44, p. 42, an. 1733,) Plater, (De Olfactus Lesione, lib. 1, cap. 9, p.
 264, an. 1736,) Horn, (in Smuker, obs.* 22, p. 289, an. 1788,) M. Savi-
 ales,  (Bull, de la Fac.  de  Med.,  t. IV., p. 44, an. 1814,) M. Graefe,
 (Annates d'Oculistique, t. VIII., 4th and 5th liv., p. 203,) Thouret,
 (Arch.  Gen. de Mid., t. XIX., p. 27, an. 1829,)  M. Brodie (Ann. de
 Therap.,  Med. et  Chir., No. 2, May, 1844,) and M. Blandin.
   M. Graefe  has  properly given them the name of rhinolites, and
 the earthy and saline materials of which they are composed are rea-
 dily explicable by the elementary composition of the secretions from
 which they are  derived, viz: chiefly from those of the Schneiderian
 membrane, lachrymal  apparatus, &c.   There is no doubt, however,
 in our minds  that earthy and saline calculous  concretions may be
 formed in any of the cavities,  passages and surfaces of the entire
 organism, and also in the  substance of any of the tissues.  Thus, at
 the Seamen's  Retreat Hospital, New York, while the writer  of this
 was at the head of that institution, a robust, tall, corpulent old sailor,
 aged 70, every way of good constitution and well formed and erect,
 and laboring under no other disease but an extensive sore on the leg,
 caused by intemperate habits, and of the character of those so famil-
 iarly  known  as " rum-legs,"  in a  fit of despondency threw himself
 from the piazza of the hospital, eighty  feet, which caused his imme-
 diate death.    In examining the dead body, in which we found every
 rib on one side fractured and extravasation into  the pleura, ventricles
 and  base  of the brain, &c.; we found  also, on inspecting the dia-
 phragm, a large regularly formed flat osseous or earthy plate, which
 was  completely  circular,  and about two inches' in diameter and a
 quarter of an inch thick  in every part of it, flat on both sides, and
 perfectly  imbedded, or as it were sewn into the middle of the mus
 cular fibres of the diaphragm, its two planes corresponding precisely
 to, and being accurately covered by, those of this partition.
  It  is to  be  remarked, as  suggested  by M. Graefe, that where an
arthritic or lithic  diathesis  exists, earthy  deposites and  calculous
concretions may be expected to be found more extensively and  in
every part of  the body.
  M. Demarquay, after his investigations, comes to  these conclu-
sions: 1.  Rhinolites may be found alone or in considerable number
in the nasal fossae, and especially in the  lower part and lower meatus
of these fossae  ; 2.  In the frontal sinus, and from thence descend into
the fossae, or into the sinus maxillare, or they may be developed in
the antrum of Highmore, as mentioned by Lanzoni (Ephem. Cur.
 Nat., deca. 3, an. 9 and 10, obs. 143, p. 267);  3. They may shut  up the
 nares and incline the septum to one or the other side, or destroy it in
  VOL. III.                     12 
90
NEW ELEMENTS OF OPERATIVE  SURGERY.
part; 4. That they vary from the size of a bean to that of a pigeon's
egg; 5. That they may be isolated, as is usually the case,  or envel-
oped in a shell;  6. That they are of a blackish, greyish, or whitish
color, and have asperities or a chagreen aspect on their surface;
and 7.  That they may be homogeneous  or may be  formed on  a
nucleus, as on the kernel of fruit, the root of an incisor tooth, &c.
  Exposed as the nares constantly are to the introduction of foreign
bodies,  and the more so in inspiration, it is easily conceived that cal-
culi might be formed entirely by aggregation of particles of dust or
fine pulverized earth inhaled from Without, without any distinct nu-
cleus, and thus  by admixture  with  the  solid depositions  from  the
secretions of the nares, sinuses, &c, give rise to the supposition of
an organic process from within the system.  This idea does not ap-
pear to  have occurred to M. Demarquay.
  The analysis of these calculi, as given  by Axman, Prout and M.
Bouchardat, is:
Animal matter (albumen, mucilage, fibrine, fat and osmazome),  0*35
Phosphate of lime,     -----       0'8
Carbonate '              -                                0-225
Carbonate of magnesia,        -                            0.125
Traces of soda, muriate and carbonate of soda, and oxyde of iron.
Mucus.
Phosphate of magnesia.
  Thus  they constitute, as M. Demarquay says, an exaggeration or
excess of the normal secretions of  the  parts.   Differing  from  M.
Graefe,  he imputes their formation not so much to an  arthritic dia-
thesis as to a chronic inflammation of the  nasal fossa and lachrymal
gland, causing a vitiated  or altered  state  of the  secretions  of those
organs.   Also an abnormally contracted  condition of  the  passages
may have an influence, by the obstruction it would create to the free
escape of the secretions.   Among the symptoms to be noted are,  a
sensation of dryness and weight in the passages, obtuse  and  some-
times acute pain, occasionally periodical cephalalgia, &c, and  finally
inflammation of the parts  encroached upon, erosion,  caries,  foetid
purulent discharges, &c.
  They may be  sometimes diagnosed  by a metallic sound imparted
to the exploring  instrument.   The treatment, when their volume re-
quires the aid of surgery, is the same as that for the extraction of
polypi, together with a more careful attention to detergent injections
and general remedies to change the morbid action.
  Successful removal of Polypi from the Frontal Sinus.—One of the
most extraordinary surgical cases on record, and one also of the most
extraordinary instances  of the  triumph of surgical art, is that of  a
boy  aged  ten years, operated  upon by Dr. C. C. Wuth, (British and
Foreign Med. Review, January,  1846, p. 186,) for a remarkable en-
largement of the left frontal sinus, with frightful  protrusion and dis-
organization of the entire left eye; both of which had existed nine
years, and caused constant severe pain in the head, loss of rest, ema-
ciation,  &c.  Many practitioners had been consulted and various
remedies used, but no  one it  appears had ever  suspected  the true
diagnosis, until  Dr.  Wuth suggested that the  whole tumor  and
deformity arose from polypi within the frontal sinus.  It is proper to 
NASAL  F08S.E.
91
state that the socket of one orbit had become so much displaced for-
ward by the internal pressure, that the left eye was almost entirely
extruded from it, presenting a most hideous aspect.  The globe in
fact lay on a level with the back of the nose, and projected laterally
over the  cheek bone on the left side, while downward it reached to the
point of the nose.  The lids for three years had ceased to cover it, and
the protrusion of the ball was the greater from the orbicularis acting
now as a powerful sphincter, excited into this forcible antagonism, Dr.
Wuth thinks, in order to resist the pressure of the tumor from within.
The cornea was partially  ulcerated, the vessels of the conjunctiva
varicose, and a constant flow of tears came  from the  parts.   The
regions of the frontal and  nasal bones were greatly protruded, and
the left side and the back of the nose formed a flat surface by reason
of the pressure, so that the nostril on that side was  nearly closed.
The skin was thickened and doughy to the touch, and the left eye-
brow deviated upwards at a great distance from the right, and had
at its outer and under part a small opening, from whence  there con-
stantly oozed  out a whitish mucous fluid.  An attack of  measles is
supposed to have been the cause of this terrible mischief.
   Dr. Wuth proceeded to operate as follows:  first by a vertical incis-
ion two inches long, from the root of the nose upwards through the soft
parts, and a horizontal one from this of the same length, close above
the  eyebrow.   Dissecting off the triangular flap thus circumscribed,
he  next  proceeded to trephine the  frontal sinus, remarking in the
middfo of the superciliary arch a small  hole  in the  bone, which
accounted for the mucous discharge already mentioned, [and but for
which salutary drain probably death would have long before ensued.
T.]  This oozing however had caused, in the soft parts of the neigh-
borhood, a considerable degree of inflammation and a fungoid condi-
tion of the tissues, which  gave rise  to some hemorrhage.  On tre-
phining into the frontal sinus by two openings, an immense quantity of
polypi protruded, being connected together like grapes,  and  covered
with a milk-white fluid.   The greater part of  these were removed
by the scissors.   Internally they were yellow and semi-transparent,
and  each had two or three vessels in them, radiating off branches in
all directions.   In the upper portion of the sinus the  polypi  were of
a mucous or cellular texture, and softer to the feel, but firm.   Out of
these could  be made too ooze, by pressure, a white slimy fluid. In
the middle of the abnormally  dilated sinus the morbid  product was
denser and more opaque; and posteriorly and towards the  parietes
it was of a fibrous  structure. The cavity terminated towards its
inner and outer sides in small sinuses or cellular  spaces, in which the
polypi lay firmly imbedded.  As the surgeon found the osseous par-
tition which separated  the sinus from the brain, so thin in fact that it
yielded  to pressure  and imparted to the finger the pulsations (the
diastole and systole) of the encephalon, great caution was required in
detaching the morbid growths from it, or in the application afterwards
of such cauterizing means as would not cause  too much irritation.
He now bored through the osseous parts from the cavity of the nose
to the  frontal sinus, as the ethmoid cells, conchae, &c,  and  intro-
duced a silver canula, so that  the fluid collected in the sinus  might
flow off unconfined; and also to  remedy the flow of tears over the 
92
NEW ELEMENTS OF OPERATIVE SURGERY.
ball, perforated the nasal bone from without inwards, so as to meet
the artificial canal previously made, and inserted in this second also
a silver tube.  This last was removed  and closed when the tears had
reacquired their natural passage.  The first canula into the sinus was
also afterwards removed, and the parts firmly cicatrized in the space
of twelve months ; by which time the globe and the bones had almost
resumed their  natural  dimensions and position; the  ulcer  of  the
cornea also having healed and left only a leucoma, but the sight much
improved.   From the first night the patient enjoyed such sleep as he
had not had for years.   The first six weeks he spent chiefly in sleep-
ing and eating, which soon repaired his exhausted constitution.  The
cure in fact has  continued complete  and perfect, now embracing a
period of some years.  To overcome the, adhesions  of the  polypi,
and to restrain new growths on the parietes of the sinus, Dr. Wuth
properly declined the  use  of  the nitrate  of  silver and employed
laudanum, Goulard's extract and creosote, pencilling the parietes
with a mixture of equal parts of the two former, and then applying a
salve composed of an ounce of zinc ointment and ten drops of creo-
sote spread on lint.
  Dr. Wuth, from the  above highly instructive case, the successful
operation for which does him so much honor, deduces very naturally
the following conclusions: 1. The power of vision to continue under
general traction and elongation of the optic nerve.  2. The frontal
sinus may be  enlarged to an  enormous extent, which, in  this case,
was equal to the volume of three hen's eggs !  3.  The return of this
osseous cavity almost to its normal form.   4. The complete division
of  the  supra-orbital  and  frontal nerves  without  injuring vision.
5.  Pain is not a pathognomonic sign of the malignant or benignant
nature of a swelling—a fact illustrated^also by cases of induration of
the mammae and other organs, which, by their spontaneous  disap-
pearance, show their non-malignant nature.
  There is  a case of a gentleman now  living in New York, aged
about 55, who  has been frequently seen  by Dr. Mott, myself and
others, and in  whom, in fact, there has existed for many years such
a frightful protrusion  of the socket and balls of both  eyes, and the
whole of the lower portion of  the frontal bones and outer angles of
the orbits, as to have excited remark among all who have ever wit-
nessed this  melancholy deformity.  The sight of both eyes is now
entirely lost, as both are amaurotic, though both balls can yet be
covered  by the lids, not however without difficulty.  The organiza-
tion of the substance  of the tunics of the globes is not materially
altered, though they both, and  especially one, stand out on  a level
with the cheek.   Is it not probable that this case is one of polypi in
the frontal sinuses ?  Some  fifteen years ago it was seriously stated,
that one day,  in  a violent fit of sneezing, one globe actually came
out of its shallow socket, and hung upon his cheek by its optic nerve
until replaced  by a physician who happened to  be present!  This
does not now seem in the least marvellous, after reading the case of
Dr. Wuth, above.  T.] 
SINUS MAXILLARE.
93
                Article II.—Sinus Maxillare.

                       § I.—Perforation.

  The maxillary sinus is frequently the  seat of diseases, to relieve
which perforation has repeatedly  been  resorted  to.   The worms,
which Bordenave, Fortassin, Heysham, &c, state to have encoun-
tered here, would unquestionably exact this operation if it were pos-
sible to recognize the existence of these animals during the life of the
patient.  The same  remarks apply to peletons  of adipocire,  which,
as it has been stated, sometimes form in this part, also to balls  which,
as Ravaton (Chir. d'Armee, p. 114) and M.  Petit (Journ. Hebdom.,
t. II., p. 47) have seen, may get caught here and remain even as long
as 25 years ; but it is especially with the view of removing abscesses,
hydropsy, ulcerations, and fungus, fibrous, and carcinomatous tumors,
also polypi, necrosis, and caries of  the cavity, that this operation is
had recourse to,
  A. Jourdain, who about the middle of the last century so strenu-
ously insisted upon  the utility of medicated  injections through the
natural opening of the sinus, and upon the inutility of its perforation
in almost  all its diseases, has not  succeeded,  notwithstanding the
numerous arguments which he advances, in convincing practitioners,
and his doctrine at the present day is advocated by no  one.  On one
hand it has  been found most frequently, whatever may have  been
said on this subject, that it is extremely difficult to discover, at the
middle of the median meatus of the nasal fossae, the entrance of the
sinus by means of a  sound; and on the other hand that this opening,
which is more frequently obliterated in consequence of disease than in
any other manner, would afford no  assistance even though  it should
be  re-established, and  that taking  all things into consideration, the
artificial perforation, which is less difficult and more certain, ought
to have the preference.
  B.  Perforation of the Alveoli.—Of the different methods of effect-
ing the opening into the sinus maxillare, the most  ancient is  not, as
is generally believed, that which consists in penetrating through the
alveoli of  the molar teeth.  Molinetti, who wrote in  1675, says, that
in a patient who was tormented with agonizing pains, a crucial in-
cision was made into the cheek, and that by means of the crown of
a trephine they penetrated into the antrum highmorianum, which
was the seat of an abscess.   It is also an error  to attribute the honor
of this operation to Meibomius.  Zwingler had, after the extraction
of several necrosed and loose teeth, cured a caries of the maxillary
bone,  by   dilating  the  diseased alveolus with  prepared  sponge.
Ruysch makes the remark that Vanuessen could not succeed in curing
a polypus until after having  extracted several  molar teeth and cau-
terized their alveoli with  a red hot iron,  so as to be enabled to pass
the finger  into the  maxillary sinus.  Some years subsequently, W.
Cowper, in 1697, according to Drake, who has formally  recommended
it, perforated the alveolus of the first molar and penetrated into the
sinus with a kind of stilette, in order to be enabled to inject liquids into
it.  Moreover Meibomius, whose researches were published in  1718,
is so  far from having  invented  this method, that he limited himself 
94
NEW ELEMENTS OF OPERATIVE  SURGERY.
 to  the extraction of a tooth, in order to give issue  to the matters
 accumulated in the sinus, with the perforation of which he appears
 to be wholly unacquainted.  It was also the practice that Saint-Yves
 followed with  success, in a patient who for a long time had  had a
 fistula, accompanied  with destruction of the floor of the  orbit; so
 that it was not until  Cheselden had revived  this operation that the
 attention of practitioners was directed  towards it.   This surgeon
 recommends that we  should  rather extract the  third  or the  fourth
 than  the first  or  the  socond  molar  teeth, as indicated by Juncker,
 and that if there exists an osseous fistula we should content our-
 selves with enlarging it in place of piercing through  the  bottom of
 the alveoli. Since that epoch the perforation of the alveoli has been
 modified by different  authors.  Heuermann,  who also prefers the
 alveolus of one of the last teeth, recommends, if the pus does not im-
 mediately escape, to  perforate the  sinus with a  probe, and  to place
 in the opening  a canula, in order to prevent its too speedy oblitera-
 tion.  Bordenave judiciously remarks, that, with  the exception of the
 first,  all the molar teeth correspond to the  sinus, and that conse-
 quently if there is one of them carious or more painful than the others,
 it is this which should  be  removed by preference, but  that it  is ad-
 visable to  extract the third if they are  all equally sound.  On the
 other hand he recommends that we should extract all those which
 are altered, provided  that they can no longer be of any service.  A
 canula of lead  appears to him to be more suitable for keeping, during
 a  certain  space  of time, the aperture open, than the sound and
 bougies, and he does not think, moreover, that the process should be
 the same in all cases.  Desault, who adopted the recommendation
 of Bordenave, commenced the operation with a  perforating tre-
 phine, mounted upon a many-sided  handle, and terminated it with
 another instrument of the same kind, but the point  of which was
 blunt, in order not to wound the opposite wall of the sinus.   Accord-
 ing to B. Bell,  if we have our  choice we ought to extract one of the
 posterior teeth, and in the interval between the dressing keep  the
 opening shut by means of a stopper of wood.   Richter perforated
 the alveolus with a trochar :  he cautions us against leaving the canula
 which is placed there  open, because  portions of  the food might  get
 into it and  be introduced  into the  sinus.  Deschamps recommends
 that we should leave  this canula  permanently  in, fastening  it by
 means of a thread  round one of the teeth.   In conclusion, the method
 called that  of Meibomius, which possesses the  advantage of placing
 the opening at the most depending  point of the sinus,  of leaving no
 visible cicatrix  at the exterior, the execution of  which, moreover, is
 as simple  as it is easy, and preferable  to every other when there
 exists a carious tooth, ought,  in my  opinion, to be rejected under
 contrary circumstances, and where the alveoli  have for a long time
 been divested of their small bones, and become entirely obliterated.
  C.  Method of Lamorier.—Lamorier  recommends  in such  cases
that we should  penetrate into the sinus maxillare, immediately below
the zygomatic  process, between the cheek bone and the third molar
 tooth.  This is the point which corresponds to the summit of the
cavity, where   the walls  of the sinus present  the least degree of
thickness, and where it may be reached with most  facility.   An as- 
SINUS MAXILLARE.
95
sistant, provided with a blunt hook, draws the labial angle outwards
and upwards.  The operator  incises the  fibro-mucous membrane
which covers the  bone, at the point designated, by means of a scal-
pel or good  bistoury; then perforates the  osseous wall with a solid
pointed instrument; enlarges the  opening as much as he judges ne-
cessary, and finishes by introducing into it a tent of lint.
   D. Method of Molinetti.—Other surgeons, going back to the ope-
ration of  Molinetti,  have  recommended that we should first divide
the cheek between the projection of the malar bone and the suborbi-
tar foramen, then  to penetrate through this wound into the interior
of the sinus; but  unless we are forced to do  so by circumstances,
we should avoid this division of the external soft parts.
   E. Method of Runge.—In place of perforators,  one sharp-pointed
and triangular, the other  blunt,  invented by Desault for this kind of
operation, Runge,  who had performed it in the year 1740, made use
simply of a strong scalpel, which,  in order to enlarge his first punc-
ture, he took care  to turn  four or five times  upon its axis.   The tre-
phine which  C. Bell uses for the same purpose, has neither more nor
fewer inconveniences  than the  scalpel of Runge or the perforating
trephine of Desault.
   F. Method of Gooch.—In a patient who  had no longer any molar
teeth, the idea occurred to Gooch of perforating  the antrum high-
morianum on its nasal wall, and of inserting therein a leaden canula.
01. Acrel  had already made use of a process very analogous: that is
to say, that after  having  operated in the manner of Cowper, he in-
serted through the nose another canula into the sinus, which had a
fistulous opening upon that part  of it.
   G. Method of Ruffel.—A buccal fistula of the sinus maxillare sug-
gested to  Ruffel the idea  of penetrating that cavity with a trochar,
and of compelling it to come out above the gum, in order thereby to
establish a counter opening.  A seton was then introduced and kept
in this passage during the space  of six weeks, with  such benefit that
success crowned the enterprise of the surgeon.
   H. Alethod of Callisen.—Callisen, who adopts the seton of Ruffel,
and  imitated in this by Zang, thinks with reason that if the  fluctua-
tion should become perceptible  at the  vault of  the palate that the ar-
tificial opening should be established there.   Busch and Henkel have
perfectly succeeded  by means of a meche introduced through a fis-
tula in the floor of the orbit, and brought into  the mouth through an
opening in the alveoli.  Bertrandi proceeded in the same manner, with
the exception of not using the seton, in a patient who could not open
his mouth and who also had a fistula in the orbitar  wall of the sinus.
  I.  Method  of Weinhold.—In  the process which is attributed to
Weinhold, the surgeon first directs his instrument to the upper and
outer part of the  canine  fossa,  directs it obliquely downwards and
and outwards, carefully avoids the branches of the suborbitar nerve,
perforates the sinus and then places a roll of lint in the  wound.   If
the sinus  has no other issue, Weinhold  recommends that we should
perforate it through  and  through, either by pushing  the first instru-
ment through the  palatine vault into  the mouth, or by means of a
curved needle above the  alveoli, when we wish to place the  coun-
ter opening external to the gum.  An eye which  both  instruments 
96
NEW ELEMENTS OF OPERATIVE  SURGERY.
have, enables us at the same time to pass through the sinus, the con*
ducting thread of a meche of lint destined to perform the duty of a
seton, and which is besmeared with any ointment  that may be suit-
able.
  J. This is a method, as we perceive, which is quite similar to that
of Ruffel or Henkel, and which may be made trial of as well as that
of Desault or Lamorier.  It is also analogous to that of Nessi, who,
after having freely laid open the sinus through the mouth, perforates
it with a trochar and proceeds to destroy also its  anterior wall to a
considerable extent below the cheek bone, or in the canine fossae.
  K.  Appreciation.—In conclusion, the perforation of the maxillary
sinus  is performed at  the point of election  or at  that of necessity.
The first may vary according to the  taste or ideas of  the operator.
The other, on  the contrary, is determined  by  circumstances.   In
cases  of abscess, hydropsy, fistulas,  and ulcerations, we almost al-
ways operate  at the  point of election.  In such cases, however
slightly one of the molar teeth may be diseased, it is to be extracted
as well as the  neighboring tooth ; we then divide the gum down to
the bone ; outwardly, inwardly, posteriorly,  and  in front, as if for
the purpose of forming  thereby a square-shaped flap, and then iso-
late it entirely  from the surrounding tissues ; after which the alveoli
are to be perforated by means of the instruments of Desault, and an
opening made sufficiently large to enable  us to penetrate with the
finger into the sinus.   Boyer, who follows  this process, insists with
reason upon the  necessity of never making the  dimensions of the
opening too small.  Should all the teeth be perfectly sound, or should
the patient have lost them  for a long time, and the alveolar border,
rounded  off and smooth, should have preserved all its  solidity, the
method of Desault or Lamorier would deserve the preference. Upon
the supposition that this would not succeed, there would be plenty
of time to adopt  that of Meibomius, which it cannot be denied  is
incomparably more painful  and more formidable to the patient.
  L.  The Author.—If, as happens frequently, and an example of
which has been published by M. Sauve, (Bull, de la Fac. de Mid., X.
V., p. 9,) the sinus is distended by any liquid, its anterior wall, swol-
len out in the form of a border under the cheek, is  in general so soft
that a bistoury or scalpel perforates it without any difficulty.  The
operation is then extremely simple.  Having freely incised the supe-
rior part of this border transversely between the cheek and the ma-
lar bone, I excise  its  inferior  portion with a second cut of  the bis-
toury.   The loss of substance thus made remains fistulous, and pre-
vents  the sinus from  filling up a second time.  The three patients
whom I treated in this  manner were promptly cured.

                § IL—Foreign Bodies.—Polypi.

  It is  also  through the anterior wall  of  the sinus that we must
penetrate  if we have  to extract only  a foreign body, as for  exam-
ple, a ball, or  shot, or some splinters of bone.  When, on the con-
trary, we wish to remove a polypus, fungus or necrosis, prudence sug-
gests that we should attack it at the point towards which it appears
to have naturally inclined, or which it has most seriously altered.  Du- 
SINUS MAXILLARE.
97
bertrand found that he could succeed in this manner in extirpating a
polypus of this kind, by uniting two alveoli by breaking through
their septum, and  then  removing the fragments of carious bones,
while Caumont .was  obliged, in  a patient  who had undergone a
similar operation  without benefit, to attack the  tumor  where  it
showed itself at the canine fossa, and Chastenet on the other hand,
found it necessary in  the case cited by him, to destroy almost the
half of the maxillary bone with its palatine  process, in  order to ef-
fect the same object.   However this may be, when the antrum high-
morianum is opened with the sole view of giving a ready egress to
the  matters which it  secretes or exhales, the requirements of the
operation  are reduced to simple detergent, astringent,  antiseptic or
dessicative injections, until the bottom of the  wound is covered with
cellular granulations.  Should there exist at the  same time necrosed
osseous fragments, these are to be destroyed.   In such cases it fre-
quently becomes advantageous to prolong the incisions, to enlarge
the openings, and to have recourse  to the chisel,  the saw, cutting
pliers, gouge and mallet.   The  same thing takes place in cases of
exostosis, and every other alteration  of the  osseous tissue.  When
the sinus  encloses a polypus, the tumor is  to be treated in the same
manner as if it  were  in the nose, with  this  difference, that the
tearing of it out, which is almost  always applicable, rarely fails to
effect our object, and that we cannot perceive at least what advan-
tage would in this case  be  presented by the  ligature,  which was
still employed by Sylvi,  (Soc. de  Sante  de Lyon, p. 121, 1798,) for
a polypus, which projected at  the same time into the mouth, and into
the zygomatic and temporal fossae.
  After having isolated and denuded its periphery, and laid bare its .
pedicle or base, it is then to be secured by a polypus forceps, or if
we should  find it more convenient, by the forceps of Museux,  fre-
quently used by Dupuytren.   We then tear it out by drawing it to-
wards us,  or what is as  well, by twisting it  upon  itself.   Should it
not possess sufficient firmness to resist the action of the forceps, we
remove it by excision after having forced it to yield as much as pos-
sible ; and if any bridles or osseous lamellae should  interfere with its
extraction, they should be divided without hesitation, unless, how-
ever, there should be some danger in  meddling with them.  When
it has more breadth than prominence, when instead of a polypus  we
find fungosities  or  any other  degenerescence,  we are sometimes
obliged to remove them layer by layer ; either by means of the ordi-
nary or blunt-pointed bistoury, by the scalpel  with a truncated, short
and  broad point, somewhat curved on its flat side, like the knife of
F. de Hilden, or that devised by Pelletan  and eulogized by Boyer,
or finally by means of any other appropriate instrument, as for ex-
ample, by a kind of cutting scoop, like  that of Bartisch.   On  the
other hand, should the tumor  be of too large a size to  be readily
extracted at the maxillo-labial  groove, it would be necessary to  lay
open the lip freely throughout  its whole height, or one of its commis-
sures in the direction which was most suitable.   The twisted suture
in a wound of this kind renders  agglutination so easy a matter, that
we should be really culpable in neglecting it whenever it should ap-
pear that the operation would  be thereby simplified. Sylvi, by cut-
  vol. in.                      13 
98
NEW ELEMENTS OF OPERATIVE  SURGERY.
  ting into  the  temporal  fossa,  in  order  to  extract  and cauterize  a
  remaining branch of a  polypus in the  sinus,  lost his  patient at the
  expiration of three weeks ; "but Cartier,  (Soc. de Sante  de Lyon, pp.
  122, 123,) after a similar operation, had  the good fortune to cure his
  Caustics may be used to destroy whatever arrachement and excision
  have not  enabled us to  remove.   The  mineral acids,  the butter of
  antimony, and better than all th:s, the nitrate acid  of mercury, intro-
  duced  by means of a pencil wrapped in rolls of lint,  have the ad-
  vantage of not transmitting their  action to a distance like the actual
  cautery, which at this point in  particular is to be especially dreaded,
  because of the proximity of the eye.   It is however important not
  to be forgotten, that Garengeot  could not succeed in  curing a fungous
  mass in the antrum which had resisted repeated excisions, extirpation
  and  chemical escharotics, except by destroying it  by means of the
  red-hot iron.   Nitrate of silver, alum, sulphate of iron or copper, and
  all those substances which  are rather styptic than really caustic, are
  scarcely applicable, in fact, except to vegetations, small ulcers and
  tumefactions ;  in a word, to alterations disconnected with the bones,
  and  which have no malignant character.   It is unnecessary to say
  that, should any deviated tooth be the cause of the disease, it would
  be necessary to proceed in  search of it and to extract it immediately.
  The triumphs of art contain in this respect facts that are extremely
  curious ;   such, for  example, is that  which Dubois has published.
  This practitioner, supposing that he was cutting down on a fungous
  tumor, saw issue out nothing but  a liquid  and thin  matter from the
  maxillary sinus, which he had  just freely laid open above the dental
  arcade.  The wound soon closed up, but the  tumor remained.  With
• the assent of Pelletan, Boyer, &c, Dubois extracted three teeth, re-
  moved a  large portion of the alveolar border,  thus  laid open the
  antrum in its whole extent,  and found  no fungus, but  perceived in
  the upper part of  the cavity, in the substance of its  anterior wall, a
  white point, which was  no other  than an incisor tooth, the root of
  which was found to be rivetted as it were into the sinus.
     M. Blasius (Arch. Gen. de Med., 3rd  ser., t. II., p. 98,)  also  suc-
  ceeded in curing  a hydropsy of the sinus maxillare by extracting an
  abnormal  tooth.   A tooth of this kind, which had  become imbedded
  in the ascending process, gave  rise to the production of an enormous
  tumor in  a patient of M. Gensoul, (Let. Chir., 1833.)  As to hemor-
  rhage,  these different manipulations sometimes render  it sufficiently
  copious to oblige  us temporarily to  suspend  the operation.   Should
  it not cease spontaneously, the eau de Ravel, oxycrat or tamponing
  with small balls of lint sprinkled with colophane,  or even if neces-
  sary, the iron heated to a white heat, are at the command of the sur-
  geon and  will always enable us to apply an efficient remedy.   It is
  also for  cancerous  and osteous-sarcomatous tumors of the maxil-
  lary sinus that exsection and amputation of the  upper jaw have been
  most frequently performed. In addition to the  examples  which I
  have elsewhere related, (see Exsection of the Jaws, Vol. II.) it is neces-
  sary to mention also that of M. Bonjour, (Arch.  Gen. de Med., ser.
  2nd, t. IV., p. 476,) that of M.  Blandin, (Ibid., t. V.,  p. 162,2nd ser.,)
  that communicated to me by M. Chaumet, that of M.  Laugier, that
  of Le Sage, (Bull, de la Fac.  de Med., t. V., p. 258,) and one which 
SINUS MAXILLARE.
99
belongs to myself.  In this last,  (Gaz. de Medecins, Prat. t. I., Nos.
1 and 2,) after  having incised  the soft parts, as has been mentioned,
(see Exsection of the Jaw, Vol. II.,) I divided the zygomatic arch, the
external orbitar angle, the ascending  process, then the dental arcade
and the nares in  the mouth, with a cultellaire saw, and removed
the entire maxillary bone  together with the cancer.

                     §  III.—Osseous Cysts.

   Osseous tumors, tumors filled with a thin serosity,  as in grenouil-
lette, or with pus, or of a fibrous, fatty or fungous nature,  or com-
posed also of many of these elements at the same time, have been fre-
quently noticed outside of the sinus maxillare,  and even in  the sub-
stance of the bones of the face.  I have seen, like Chaussier, exostoses
in  the  lower jaw.  M.  Diday  (These de  Concours. 1839, p. 32,)
mentions one situated in the vault  of the  palate.  M.  A.  Cooper
saw one which caused suffocation by pressing upon the epiglottis.
Runge, who was one of the first that spoke of these tumors,, states
that his father and himself have met with osseous tumors in both jaws,
and that they frequently derive their origin from the point  of the
root of a tooth.  It is also probable that those alleged lymphatic con-
gestions whose walls  were found as  thin as parchment, and  which
M. Brodie,  (S. Cooper, Surgical Dictionary, p. 201, 7th ed.) as well
as Kirkland, places in the antrum highmorianum, also belong  to the
same description of disease.  Has not Callisen committed a like error
in speaking  of  those tumors  with separate compartments, which,
according to him,  require the  extraction of several  teeth ?   Siebold,
who saw an osteo-sarcdma between the laminae of the sinus, and who
exsected it without causing any pain,  and cured his patient, has dis-
tinguished better than his predecessors the actual  location of this
disease.  In fact Runge, who in other respects describes it sufficiently
well, and does not omit to mention that by pressing it with the finger
it  yields, but immediately reacquires its dimensions with  a  bruit,
ranges it among diseases of the sinus.  Sprengel also  charges him
with several times having  inserted in his dissertation, through inad-
vertence without doubt,  lower jaw for upper jaw.  In this  respect,
the learned historiographer was evidently deceived.  It is certainly to
the lower jaw that Runge has reference when he designs to speak  of
it.  Only he has made use, erroneously and improperly, of the term
sinus, to designate tumors which are  situated external to these cavi-
ties.  These isolated facts, moreover, had not attracted the attention
of any one, and it is to Dupuytren  to wh^m we are indebted for
having been the first  to give in  his clinical lectures exact notions on
the disease in question.   I have now se<*i a  great number of exam-
ples.   Though the tumor may be situated outside of the  sinuses,
since it is more frequently seen in me lower than in the upper jaw,
and in the ascending process as  well  as in the substance of this last,
nevertheless almost always has certain relations with a diseased con-
dition of the teeth.  M/Diday,  (These de Concours,  1839, p. 36,)
adopting this idea,  seems even to think that osteo-serous cysts  of the
face almost always proceed from  a dental follicle, and that the greater
part of them are disconnected with the substance of the jaw.   Though 
100
NEW ELEMENTS OF OPERATIVE  SURGERY.
they are similar in form and external appearances to carcinomatous
or fungous tumors, they differ from them especially in this, that they
are readily cured by surgical means.   Analogy authorizes us to sup-
pose that the various kinds of treatment  extolled for lesions of the
maxillary sinus would be equally applicable to them ; that by extract-
ing the carious teeth in the neighborhood  and opening into them at
the inner side of the lips or cheeks when they are so situated as to
allow of it, we should effect the cure  of a great proportion of them;
so that there would be no great mischief from confounding them with
polypus or other tumors developed  in the antrum highmorianum,
as happened to the father of Runge and to Dupuytren himself.  But
up to the present time at least,  I have always found it to suffice,  as
Dupuytren also did, to incise them freely in the mouth or through the
cheek, then to throw up injections, and to insert daily a meche or tent
of lint in the wound, in order  to bring about their diminution and
resolution.
      CHAPTER  V.

  AUDITORY APPARATUS.

Article  I.—External Ear.

      § I.—Otoraphy.  '
  Pibrac and those who like him, in the last century, condemned the
abuse of sutures, were wrong in proscribing also  those of the ear.
Though it be true that in wounds  of the pavilion of this organ, ad-
hesive plasters, position and  a  bandage, sometimes suffice for pro-
curing a healthy cicatrization, it is also true that these means are for
the most part uncertain, and that the suture is infinitely preferable to
them.  When it is used, whether in the form of the interrupted or whip
suture, or in any other manner, I  see  no reason why the  skin only
should be included, and that we should place as many points  of suture
behind as in front, in  order  to avoid the cartilage, as the ancients
recommended.   Leschevin has clearly shown, and M. H. Larrey has
since proved, that there is no inconvenience in comprising the whole
substance of the  pavilion in the nooses of the thread.   All wounds,
for example,  by a cutting instrument, and which divide the externa!
ear through and through, ought to be  immediately reunited by the
suture.  Ancient divisions, after  having their borders abraded, should
be treated in the same manner, conforming ourselves in other respects
to the rules laid down in the article on harelip.   (See Otoplasty,


                   § II.—Tumors of the lobe.

  The lobe  of  the ear may be  the seat of tumors  of a large size •
those that are pyriform, indolent, homogeneous or somewhat granu- 
EXTERNAL EAR.
101
lated, fibrous or elephantine.  A woman had one of unequal size on
each ear ; having removed by a V incision into the sound tissues, that
of the right side, which was of the size of a nut, I was enabled to re-
unite the wound by two points of suture, and to cure the patient in
three days.   It would appear, moreover, according to M. Campbell,
(Arch. Gen. de Med., 2d ser., t. VI., p. 110,)  that this description of
tumors, which frequently originate from  the  helix, is apparently
endemic at Nipel.


          § III.—Deformities of the Meatus Auditorius.
   A. When atresia of the passage  of the ear is complete, and that
its source lies in the temporal bone itself, a double example of which
I saw in the  dead  body of a child four  years  of age, and a second
instance on  one side only in  another child of from ten to twelve
years  of age, it is  incurable, and yields to  no kind of medication.
To whatever degree, on the contrary, the contraction may have pro-
ceeded, even  though it scarcely admits of the passage of a needle,
as was seen by Lametrie, or that the coarctation is trifling and occu-
pies only one point of the passage, or has invaded the whole extent
of the canal, we should make an attempt to remedy it by dilatation.
Caustics, which were preferred by some ancient authors, might  under
these circumstances become dangerous and would rarely effect the ob-
ject in view.  The  canulas, sounds or tents of larger and larger size,
that are used, should be still continued a long  time after the cure, and
even sometimes during life ; for the wall of the canal retains almost
always a great tendency to contract  again.   In certain cases the
walls of this canal,  when simply lying in juxtaposition to each  other,
cannot be  effectually separated except  by  a metallic  canula of a
diameter corresponding to that of the auditory passage in the normal
state.  If the  deafness  depended evidently upon an anomaly in the
curvature of the cartilaginous prolongation of the ear, it could be
remedied  by placing a gold  canula  permanently in this passage, an
example of which is related by Boyer in  his practice.
  B. More frequently the external ear  is shut up  by a membrane or
a sort of diaphragm.  Unless  it should  be very remote from the
pavilion, this  membrane should be  laid  open by a crucial  incision
with the bistoury.   The  flaps are afterwards  to be excised with the
same instrument or a small pair of  scissors, while they are succes-
sively raised up by means of a hook.   Others have recommended that
it should be perforated with a trochar, and its destruction completed
by the aid of dilating bodies ;  but this method is not as good as the
first.  Incision, which Paul of Egina adopts when the accidental dia-
phragm is deeply situated, as in the preceding  case, rejected by F.
ab Aquapendente under the pretext that it incurs the risk of penetra-
ting into the internal ear, is not proscribed at the present day, except
in cases in which it appears to touch the membrane of the tympanum.
In these  cases we  follow the precepts  of J. Fabricius,  and  have
recourse to caustic, and  the best without contradiction is the lapis
infernalis.   Leschevin recommends  that  it should be inserted  in a
piece of quill, and  applied  to  the bottom of the  passage through a
silver canula.   Three or four cauterizations, at intervals of two or 
 102           NEW ELEMENTS  OF OPERATIVE SURGERY.

 three days, are generally sufficient.  If, however, the septum should
 be very thick, it would be better, after the manner of Leschevin, to
 perforate it atwhatever depth it may be situated, by means of a very
 short trochar, whose stilette passed but a very slight distance beyond
 the end of the canula.
  C.  It is by the same treatment that  we should attack every kind
 of atresia, complete or incomplete, which is imputable only to defect
 of conformation of the soft parts, and which is not purely membranous.
 As soon as the instrument has  passed beyond the obstacle which the
 sudden removal of the resistance indicates, the trochar alone is to
 be withdrawn, in  order to  use its canula for the introduction of a
 bougie to the bottom of the  auditory passage, which is to be renewed
 daily, gradually increasing its size.

                    § IV.—Foreign Bodies.

  A.  An infinite number of varieties of foreign bodies may become
introduced in the auditory passage, and  an infinite number of means
have been proposed for their extraction.  Archigenes, in compelling
the patient to hop on  one  foot,  and to take sternutatories, had  the
 same intention as Celsus, who recommends us to press his head upon
a table and to shake it with force, either by raising him up by the feet
or striking his sound ear, or letting suddenly fall again, after having
raised  it, the body which supports him.  Alexander of Tralles  has
suggested the idea of sucking upon them with a tube; and  Mesu6,
who has revived this, like J. Arculanus, has devised for this purpose
another instrument, destined exclusively to  pump out liquid matters.
The suction pump, the instrument  invented  by M. Deleau,  and
which can serve to withdraw the air, serosity, pus, &c, as well  as
for  injections into the ear, are  referable  to the same  principle.
Leschevin, who  alledges that the air contained in the  canal of  the
external ear is the  ordinary cause of the buzzing sound  and tinglino-
in the ear, had been anticipated by Reusner, who, in order to remedy
this inconvenience, recommended a small silver  canula left  perma-
nently in the auditory passage.
  B. Hardened wax is  dissolved  very well by means of oil of sweet
almonds, as is remarked by Avicenna, and better still by means of
tepid  soap and  water,  or even in pure water, if we believe in  the
experiments of Haygarth, who rejects  oils as less serviceable.   A
solution of sea salt, as  eulogized  by J. E. Trempel, also dissolves it.
Consequently, when deafness is produced, as so frequently happens in
persons of a certain age, by the  accumulation of this  material,  we
cause to be  introduced several  times  a day into the ear  one  of
these liquids, either by means of a syringe, or upon cotton which has
been saturated with it, and when  it has become softened or detached
it is removed by means of a scoop,
  Duverney, (Traiti de Vorgane de VOuie, 3d part, p. 156,157, 1683,)
states that he had seen in eight or  ten instances  the wax so inspis-
sated as to resemble plaster, and filling up exactly the bony and carti-
laginous passage of the ear.  Distinguished surgeons had communi-
cated to him more than  thirty similar examples.  This species of
deafness, according to him, is the most common and the most easnv 
EXTERNAL EAR.                      103
cured.  A famous surgeon of Mons who obtained  so  much renown
for the cure of deafness, undertook only the  treatment of this form
of the disease.   In  a patient who had been affected with deafness
for a long time, the cavity of the tympanum had become excessively
dilated, and the petrous portion  of  the  temporal bone  absorbed.
These two  singular affections were  produced, says M. J. Cloquet,
(La  Clinique des Hdpit., t. IV., No. XXL, and Siance Acad. Mid.,
1829,) by the development or accumulation of  a ceruminous matter
which had become indurated in the interior of the cavity of the tym-
panum, and which was thrown off in scales, forming a species of false
membranes.  In another case noticed by M. Jobert, (Revue Med.,
June, 1830,  p. 414,) the  cerumen  which filled up the cavity  of the
tympanum, had transformed  the petrous portion into an osseous dila-
ted cavity, in which there remained  no vestige of the conformation
belonging to the middle  and  internal ear.  The woman mentioned by
Bartholin, (Act.  Haffn.,  t. I., obs. 45, p. 82, and Planque, t. XVIII.,)
experienced severe  pains, especially in the petrous bone.   In clean-
ing the right ear she extracted from it, together with fetid matters,
a quantity of sand,  and  then experienced no more pain.
  C.  Should bugs, earwigs, and other insects, (Wolckamer, Rayger,
Lieutaud, (Sauvages, Nosol.,&.c, t. IV., p. 232,) Alteyrac, DelaMotte,
Drouin, and Acrel, have  noticed worms here ; M. A. Severin, Drouin,
and Planque, caterpillars ; Ravaton and Wolckamer earwigs ; Binnin-
ger and Schenk, the larvae of flies.) which sometimes get into the bot-   •
torn of the auditory passage,  not become entangled in the cotton and
pitch, as had already been  recommended by  Hippocrates, or in a
piece of lint saturated with turpentine,-which are  introduced, in or-
der that they may become caught in it, we may after the manner of
Hameck, endeavor  to kill them by pouring into the ear the oil of bit-
ter almonds, or  like  Rhazes,  a decoction of peach-leaves.  The de-
coction of Sedum palustre, used by Acrel, would produce the same
effect.   But it is useless at the present day to combat with Verduc, who
thought that the pippin apple possessed the property of drawing them to
the outside; or  with Leschevin, who  boasted of the half of a potato
being a special antidote for the earwig.  It is nevertheless true that
that  milk appears to possess the  property of attracting  an  earwig,
and that M. H. Berard, as well as Alteyrac, succeeded in effecting the
expulsion of worms from the auditory passage, by holding a piece of
meat upon the ear.   It is to be mentioned also, that whether living or
dead, we should endeavor to seize hold of these insects and extract
them by means  of the forceps.
  D.  As to solid foreign bodies, of a certain  volume, and  which
Paul of Egina has properly ranged  into  two classes, namely, those
which absorb humidity, and  may become distended in the parts, and
those  which are impermeable; (MM.  Betbeder, Begin, and  Cham-
pion, speak of oat-seeds and  barley-ears ; Dupuytren, of  a piece of
pencil; De  la Motte, of a pea; Saucerotte, of beads of a  rosary;
F. de Hilden and MM. Dumoustier, Champion, Faber, and M. Mau-
noir, of cherry-pits,)  they demand all the  attention  of the surgeon.
Acute inflammation, abscesses, caries of the bones, cerebral accidents,
and violent pains of the  head may be caused by their presence.  At
the opening of the dead body of a patient who died  in this manner, 
104
NEW ELEMENTS OF OPERATIVE SURGERY.
Sabatier found the os petrosum perforated, the dura mater inflamed,
and an abscess, together with a small ball of paper, which was the
cause of all the difficultv, in the  substance of the bone itself.  In a
young girl who had  suffered for a long time paroxysms of convul-
sions, and all kinds of nervous accidents, F. de Hilden (Bonet, Corps
de Med., t. II., p.  405, obs.  4) effected a complete cure by extracting
from the ear a foreign body which had been  introduced  there seven
years before.  An analogous observation was published in  1829, and
scientific collections are crowded with similar examples.
  E.  M. Larrey  nevertheless remarks that in  a soldier  whom he
treated, the foreign body had  remained in its place during ten years
without producing any accidents.   It is well  also not to forget  that
these different bodies,  which  may be a bean, a  small ball  of bread,
wood, shot, glass, iron,  a small pebble, pin, needle, clot of blood, &c,
sometimes  come  out  of themselves  when  the first  accidents  have
passed over, after  having produced a suppuration more or less abund-
ant.   An important point to be noticed in practice especially is this,
that  patients frequently, as well  as their friends, are determined in
persisting that there is a foreign  body shut up in the ear when it is
completely free.   A woman greatly alarmed  brought her child five
years of age to one of the public cliniques in the capital, in order
that  she might have removed from his ear a cherry pit which had
been there  for the space  of twenty-four hours.   All  kinds of at-
tempts were made, and these being uselessly repeated every morn-
ing for  three days, caused excessive  pain, inflammation and fever,
until when it became hazardous  to do anything more, and the idea
suggested itself of ascertaining whether the organs of the little pa-
tient actually contained the  pit  sought for, it  was perceived  that
there was nothing there.  Such mistakes have frequently given rise
to the most serious accidents.  Boyer relates two instances ; I have
met with three or four, and there are few physicians who have not
had occasion to witness the same.
  F. If by inclining the ear downwards we cannot  extract these
solid foreign bodies, we must endeavor to reach them by  means of
the forceps when their form is elongated or flattened.   A small hook
is sometimes the best instrument that can be used for removing those
which have a certain degree of softness.  It is for these last also that
it is advised to divide them and reduce them into fragments by means
of a narrow and elongated myrtle-leaf probe, in order afterwards to
withdraw them by piecemeal.
  G. Fragile bodies exact much more  precaution.  A  false pearl,
says Boyer, which had  become broken in the auditory passage, by a
surgeon who was  endeavoring to  extract it, put the life of the patient
in danger, and caused a suppuration of the tympanum and the  loss
of hearing.   We  must  therefore undertake their search by means of
a delicate scoop, which however is to be of sufficient solidity, by fol-
lowing the lower  wall of the canal in order to introduce it below the
body which is to be removed, and afterwards making use of it as a
lever of the first  kind,  by depressing its handle at the moment of
making the extraction.   The  scoop modified by M. Leroy, which is
terminated by an  articulated beak which is to be introduced straight,
and  which is to  be  elevated by the turn of a screw when it has 
EXTERNAL EAR.
105
passed beyond the  foreign body, almost always  succeeds in such
cases.  A noose of lateen or brass wire, or a hair pin, much esteemed
by M. Champion, if introduced and brought out in the same manner,
would be equally efficacious.
  H.  A cherry pit which  had resisted  all such manoeuvres, finally
germinated in the ear to such extent, if M. Donatus is to be believed,
(De Med. Hist. Mirab., lib. II., cap. 22, fol. 77,) that it then became
practicable to extract it by drawing upon its  twig; but  there is no
necessity  of  pointing out  the  improbability of a statement  of this
kind.   Verduc (Operat. &c, p. 224, 1721,) however, also states that
a pea had germinated in the auditory passage, and M. Dumoustier
(Reflex, sur les Corps  Etrang., Strasbourg, 1810, p.  5,) makes the
same  remark of an oat seed as Donatus does of his cherry pit.  In
such cases the only resources applicable would  be  to oppose the
symptoms with energy or to  prevent  them,  to  as great a  degree
as it was in the power of art to do, and then  to await the suppura-
tion.
  I. The process of F. de Hilden, as adopted by C. de Solingen, and
which has been properly rejected, consists in introducing a first ca-
nula down to  the foreign body, then through this last a second canula,
intended to secure this body by means of the teeth which are pla-
ced upon its extremity, while a kind of screw-ring or gimlet is in-
serted to extract the whole  at the same time.   That which the scoop
could not do  would not be more advantageously effected by this ap-
paratus, which is much better calculated to force the foreign body
into the  cavity of the  tympanum than to bring it to the exterior.
The eyed ear-picker of F. de Hilden, Ravaton's  hook, BrambihVs
scissors, Leschevin's hook, the flattened  probe of Andrieux, and the
curved forceps of Dupuytren  are not as valuable as the  forked pin
of M. Champion, and  the  articulated scoop of M. Leroy.   In two
instances M.  Begin, (Elem. de Pathol., 2nd edit., p.  521,) has  suc-
ceeded without any  difficulty  in extracting cherry pits  which had
got introduced into the bottom  of the auditory passage, by means of
a small slender iron  rod slightly curved  in the form of a scoop: a
vibratory movement made upon the instrument caused the expulsion
of the foreign body.
  J. In difficult cases  Paul made a semilunar incision  behind the
concha, in order to penetrate to the bottom of the passage, by open-
ing through the cartilage from without  inwards, and to be thus ena-
bled to force out the foreign body from within outwards, by means of a
suitable instrument.   This operation, again recommended by Dionis
and Verduc,  is now wholly  abandoned.  It  should  not, however,
perhaps, be entirely rejected when the danger presses, and all other
means have been fruitless.
  K.  Injections thrown in with some force, eulogized by M. Dumous-
tier (These, Strasbourg, 1810, p. 5,) andM. Mayor, (Journ. des Conn.
Med., t. III. p. 13,) already employed at the time of Celsus, and cen-
sured by Scultetus, and which had been  used with advantage by a
surgeon of the acquaintance of Morgagni, (Lettre XIV., p. 334. Art.
XIII.) would  be applicable if the foreign  body had but little  size, or
was light.  It is however  obvious that the  douche  and injections
through the Eustachian tube, as recommended by M. Deleau, (Gaz.
  vol. in.                     14 
106
NEW ELEMENTS OF OPERATIVE SURGERY.
 Med. de Paris, 1835, p. 303,) could not succeed unless the membrane
 of the tympanum was ruptured.  We must always, moreover, before
 commencing the operation, and whether we use this  or that  instru-
 ment, instil some  drops of oil into the ear, in order to render the parts
 smoother, and less irritable.  Afterwards, nothing remains to be done,
 except to throw up  emollient  injections during the  space  of some
 days; unless, however, the manipulations made use of should  induce
 us to apprehend the subsequent development of formidable accidents.
 Under such circumstances, the antiphlogistic  treatment with hypno-
 tics and calmants, should the pains be acute, become  indispensable.
   [Foreign Bodies—Ear.—-Mr. Carpenter, of Castelcomer, (Dublin
 Medical Press, June 20,  1841,) has met with remarkable success m
 detaching, and  then extracting foreign bodies  wedged against  the
 tympanum, in the meatus of the ear, such as  garden peas, pebbles,
 &c, by injecting  cold water with  force into  the passage, by means
 of a syringe containing two ounces or more. T.]

                          § V.—Polypi.

   A. All the different modes of treatment which have been adopted
 for polypi of the nasal fossae, have  been prescribed also for those of
 the ear.   Aranzi  alleges  that they may be  cured by means  of  red
 precipitate ointment. De Vigo employed by turns for this purpose, the
 red hot iron, caustics, and the  ligature and forceps.  Paul removed
 them with a  bistoury made expressly for this purpose, or by  means
 of his pterygotome.  G. de Salicet cauterized their root, after having
 ligated them with a  horse-hair or silk thread.   The ligature and  ex-
 tirpation are  almost the only two methods employed at the present
 day-
   B.  The  ligature,  which F. de Hilden, Marchettis and Purmann
 adjusted by means of a silver plate curved in the form of a forceps,
 is rendered more practicable, says C. de Solingen,  by previously
 traversing  the  base  of the tumor  by means  of a  thread, as  a sub-
 stitute for an erigne.  It is in reality applicable only in  a very small
 number of cases, and for  those polypi which have a narrow pedicle
 and in near proximity to the pavilion.  It is executed  by means of a
 hempen  thread and  the canula of  Desault, or by the process of F.
 de Hilden, as modified by Solingen, or what  is still as  good,  by in-
 troducing with  the forceps, and causing it to pass in with  a probe, a
 running-knot or noose of the thread  as far down as to the root  of
 the polypus.  After the ligature is placed, by whatever mode it may
 be, its two ends are introduced into a knot-tightener, and from this
 moment the operation has nothing particular.
  C. Excision is practicable under the same circumstances, and almost
in all cases where the ligature may be made trial of.  The polypus hav-
ing been secured with an erigne, we draw it towards us, while revers-
ing it slightly in order to lay bare its  root and divide  it with one cut
of the bistoury.   De  Lavauguyon, B. Bell, &c, who prefer this  to
the other methods, have not found it necessary in order to perform
it, to make use of the hook-shaped  knife of F. de Hilden; but it is
evident  that  the narrow, blunt-pointed scissors, which  are slightly
curved flatwise, could be advantageously substituted  for the bistoury. 
                        EXTERNAL  EAR.                      107

   D. As  to  arrachement, the only method in my opinion which
can  be advantageously applied to polypi  whose  roots are deeply
situated, and which, if necessary, would answer also for the others,
it may be effected by means of the ordinary  hooks, and the eyed
scoops, which are  thin and  garnished with teeth.  The  speculum
auris ofG. Fabricius, that of Cleland, as well as all those which have
been proposed before and since are useless, if not injurious.  Hooks
now take their place.   The surgeon opens them gently, inserts them
between  the  tumor and the walls of the canal, which he carefully
dilates ;  causes  them in this  manner to glide  as  deep within the
cavity as possible, and when the polypus is firmly seized  he turns
them upon their axis, and then tears out the whole with a half draw-
ing  and  half twisting motion.  The blood which escapes at the
moment  conceals the  parts to so great a  degree, that in most cases
we are obliged to defer till the next day the exploration necessary to
ascertain whether there exists or not, anything  more in the auditory
passage.   This  hemorrhage, however,  is  never dangerous.  A tent
of lint besmeared with cerate, or a pledget of lint of the same kind,
to prevent the bleeding surfaces  from  being irritated from  contact
with the air,  form all the dressing that is required, and which more-
over is always made use of after extraction of polypi from the ear.
   E. However  little there may remain of the  heterogeneous tissue
after the operation, we must endeavor to  destroy it, not with the hot
iron as recommended by G. de Salicet and F. de Hilden, &c, but
by means of caustics, which, in  our time, generally have  the  pre-
ference.
   The canula of J.  de Vigo, which is to have an opening on the side,
after the advice of  Marchettis, Verduc, &c, enables us, it  is true,  to
apply the  cautery  exclusively upon  the diseased point; but as we
are sometimes under the necessity of acting upon large  surfaces,  or
very near the membrana  tympani,  the  actual cautery must here
necessarily be attended with  some degree of danger.  Nothing, on
the contrary, is more simple than to reach  the polypus through the
same canula  by means of a  hair-pencil besmeared with butter of
antimony, nitrate of mercury or  any other  caustic, even supposing
that  the lapis  infernalis could  not be substituted for these  different
articles.   Instances  of polypi of  the ear  cured by extraction have
been also related in the Clinique of M.  PI. Portal, (vol. I., p. 265,
306 x
   F. Polypi  of the  ear are so slowly developed,  and produce so little
disturbance of the functions  in certain subjects, that  many patients
have them for years before asking to be relieved of them.   In Feb-
ruary,  1830, I extracted one  at  the hospital of St. Antoine in an
adult man, in  whom it had existed for fourteen years.  Their extrac-
tion  in such  cases  is not unattended with some danger.   The tym-
panum, which has been  shut  out for a considerable length of time
from the action of its appropriate stimulants, would be irritated by
their presence if they were removed without caution.  It is the same
as with an eye which  has been operated on for  cataract: it must  be
first  kept in  darkness and  not afterwards  be exposed to the light
except by imperceptible degrees.
   G. Polypi  of  the ear sometimes acquire a considerable size.;  that 
108          NEW ELEMENTS OF OPERATIVE  SURGERY.

mentioned  by Sussius  (Gerdv,  These de Concours, 1833, p. 144,)
exceeded the size of the fist.  A woman whom I had for some weeks
at the hospital of La Charite in 1838, had one which was scarcely less in
size.  I saw the same thing in a voung man in 1837. In a female aged
twenty-nine years  M. Itard  (Mai.  des Oreilles, t. II., p. 125,) found
one which was an inch  and a half long; but it is not clear that many
of these unusual examples did not belong to the class of sarcomatous
fungi, either of the dura mater or neighboring bones.   In  order to
remove a tumor of this description in 1835, in  a peasant aged twenty-
seven years, I was obliged to slit up the pavilion behind, transversely,
then to have recourse to a small  knife, curved on its flat side, in
order to detach the tumor from the  bottom of the cavity of the tym-
panum ; I then saw that the fungus did not  stop in its limitations in
the  ear, and that it would repuUulate.  The patient having survived, I
cannot say if, in this case, the dura mater was in reality the source
of the disease.

                  Article II.—Internal Ear.

          § I.—Perforation of the Membrana Tympani.

  Plemp is the first, I believe, who  has maintained that the function
of hearing  may continue although  the membrane of the tympanum
has  been perforated.  The fact he relates in support of his asser-
tion  appeared  at that time  so extraordinary, that Verduc refuses to
place confidence, in it,  while Valsalva,  who  speaks  of experiments
made upon animals, also denies its possibility, in spite of the authority
of Riolan, sustained upon the example of a deaf mute, who having
plunged an ear-picker through it, immediately regained his hearing.
  Cheselden went farther; since, says he, the loss of the membrana
tympani does not produce deafness,  we might perhaps, by perfora-
ting it in some persons re-establish the faculty of hearing.   Unfortu-
nately his operation  was unattended  with success in the criminal
upon whom he first put this suggestion into practice.  Though again
pointed out by Portal,  and  formally  recommended by Busson, as a
means for evacuating abscesses of the cavity of the tympanum, per-
foration of the tympanum could not be rescued from oblivion, but
by M. A. Cooper, who  first practised  it successfully as a remedy for
deafness  in 1800 and 1802.  Since made trial of with different re-
sults by numerous surgeons, it is again ranked among the useful and
systematized operations of the healing art.   A small  curved trochar
is the only instrument that was used by M. Cooper, who in order to
avoid touching the  malleus and the  chorda tympani, properly advises
that we should perforate the membrane at its anterior and inferior fourth.
  Himly, who pretends to have publicly described this operation in
1797, states that the opening soon closes up when we use the trochar.
In order to avoid this inconvenience we may perform it with a punch,
which M. Fabrizi, of Modena, (Journ. des Progres,  t. VII., p. 153,)
has  ingeniously simplified.  After this remark, the cataract  needle
preferred by Arnemann, the small square-shaped knife as well as Hey's
needle, with which Buchanan  proposes to divide the fibres of the
membrane transversely, and  thus favor the retraction of the lips of 
internal  ear.
109
the wound, together with the triangular sound of Paroisse and the
concealed kystotome of Fusch, ought to be proscribed, as well as the
small stilette armed with a circular shoulder near its point, invented
by M. Rust, the knitting needle, which according to Michaelis might
equally be adopted, the simple probe of Itard, the needle that Saissy
incloses in a small gum-elastic canula, and the kystotome of La Faye,
which to myself appears to be more convenient than any other in-
strument.  Finally, it was  also with a view of having a permanent
opening, that M. Richerand supposed that it would be better  to per-
forate the tympanum by cauterizing the  membrane with a  crayon
of nitrate of silver, and that  Zang  suggested the idea of leaving a
catgut in the wound.
   To the three  successful  cases of A. Cooper, we must now add a
great number of others.   Those of Ansiaux, (Clin.  Chir., p. 260,
2nd edit.,) and of Sanders for example, who has cured a deafness
of three years' standing by means of this operation ; another of Pa
roisse, in a patient who had been  deaf for eight years ; those of  Mi
chaelis, M. Rust, Itard, Saissy, Maunoir, and  Herhold, which lattei
states that he succeeded in two cases out of three ;  and those of M
Fabrizi, who informs me he has  cured in more than ten instances;
but we must not however dissemble that most  of those practition-
ers, as Celliez and  Itard among others, and Dubois, in four different
trials, have also  performed it without deriving the slightest benefit
from  it.   Trury and Kauerz have not been, I believe, any more suc-
cessful.  It is moreover  applicable, but in  a very small number of
cases.  We should be wrong therefore to expect any benefit from it
when the cause of the deafness is found  to  be a lesion of the laby-
rinth, or of the middle portion of the ear, or of the nerves or small
bones, or of their muscles; in a word, wherever the  disease does not
consist merely and simply in the obliteration of the Eustachian tube,
or in  a thickening or any degenerescence whatever, of the mem-
brane of the tympanum itself.  Its  object in fact, is to admit the air
to enter into the cavity  of the tympanum  and the mastoid cells.
Pus, serosity, mucosities, and  other liquid matters, of which it might
also favor the egress, would not require  this operation unless there
should not exist the more natural route through the pharynx.   More-
over,  it is not dangerous, nor  does it give rise to very serious acci-
dents.   Being attended with scarcely any pain, and  rarely followed
by a general reaction, there is no objection to making trial of it when
we have no longer any thing  to hope for from other remedies; only
that we must not promise ourselves  too favorable results, or build too
sanguine hopes upon it.  The simple puncture moreover is of no ser-
vice. .  The aperture often closes upon the following day.  Excision
itself, when a proper instrument has not been at command, is not free
from this inconvenience.  M. Deleau's punch, which is a kind of con-
cealed spring  which  slackens at  the pleasure of the operator, and
which suddenly pushes against each other two  small circles with
sharp cutting  edges, in such manner as to detach a perfect disc from
the tympanum, though one of the most perfect instruments, is  still far
however from being always attended with success.   There is scarcely
any instrumental apparatus than  that of M. Fabrizzi, which will in
this respect fulfil every indication. 
110
NEW ELEMENTS OF OPERATIVE  SURGERY.
             §  II.—Perforation of the Mastoid Cells.

   A. When, in consequence of inflammations that are acute or even
chronic, severe,- dull, or tensive  pains are found to  exist in the ear,
—when we  have strong  reason for believing that an  abscess has
formed in this part,—that  injections into the cavity of the tympanum
would be advantageous, or that there are  some carious bones  or
splinters to be removed, perforation of  the mastoid  process appears
to be very clearly indicated.  The passage in which Galen says that
where ulcers of the auditory canal have altered  the hard parts, we
must make an incision behind the ear and rasp the bones or remove
their splinters, is all that we find in the ancients that appears to have
reference  to  this  subject.   But Valsalva  had already made  the  re-
mark that injections forced into  the mastoid cells come  out  by the
mouth.  Riolan and Rolfinck  expressly mention  trephining the mas-
toid  process.   Heuermann, who saw an abscess of  the ear make its
exit  in that part, and leave a fistula there, concluded  therefore, like
Duverney in  speaking of the surgeon Deymier, that the best thing  to
be done in such cases would be to apply the  crown of a trephine be-
hind the concha, without giving time for  the  pus to make too pro-
found an alteration in the spongy  texture  of the process.  A  patient
who would not submit to this operation, recommended by J. L. Petit,
died, while by means of it the same author cured a certain number
of other patients who were at least as  severely affected.  Observa-
tions of the  same kind have been published  by Morand, Leschevin,
J. Frank, Martin, &c.  It  is principally upon these that Jasser justi-
fied  himself  in operating upon the soldier, in whom he  opened the
mastoid process on one side, containing an "abscess with caries, and
that  of the other side in  consequence of a  simple deafness.  Fiedlitz
has performed this perforation successfully on both sides in a woman,
who had been rendered  deaf by a quartan fever.   The same author,
as quoted  by Richter, relates  two other cases not less remarkable.
Laefler, who  eulogizes it greatly, recommends that we should make
use of a perforating trephine, armed with a border, which prevents
it from penetrating too deep; that we  should  incise the soft parts
twenty-four hours before perforating the  bone, in order  to have no
blood effused into the mastoid cells ; and that finally, we should make
use daily of injections into  the opening, which is to be kept open and
dilated by means of a leaden sound.  Hagstroem, who however has
had no reason to  be satisfied with this  operation, enters  into  many
more details  upon the  mode  of  performing  it than Laefler,  whose
ideas he for  the  most part adopts.  If  there already exists a  fistula,
he says we should confine ourselves to  enlarging it.  Otherwise we
lay bare the bone while  avoiding the  auricular artery, which  is
naturally nearer to the  concha;  after which we have nothing more
to do than to  perforate the  process from behind forwards, by  means
of a drill, a punch, or a trochar, rather than with a perforator.   Acrel
considers  trephining the ear  useless when the bones are  sound, and
Murray has very properly observed that before the  age  of puberty,
as the mastoid  cells are scarcely then  developed, it could in reality
then be attended with  no advantage.   The case  of Dr. Berger,
who died after  having been  operated  upon by Koelpin,  and  in 
INTERNAL  EAR.
Ill
 whom no cells were found, proves  that they may be wanting also
 in  some  adults.   Similar facts  related by Morgagni, however, did
 not deter either Proet or Arnemann, who assure us that they have
 had recourse to it with  success.   Hydropsy of the cavity of the
 tympanum and simple abscesses do not absolutely require it.  They
 are evacuated full as well by perforating the membrane of the tym-
 panum, which is infinitely less painful  and  less severe.   It is only
 after all in collections of pus, accompanied with necrosis or caries,
 and which have a tendency to open behind  the ear, that we  are to
 some extent obliged  to have  recourse  to it.  In a case  of this des-
 cription,  M. Weber, who found the mastoid  process sound, after
 having trephined it, nevertheless cured his patient.  M. Denonvilliers,
 (These d'agregat., &c, 1839, p. 72,) in analyzing  fourteen of these
 operations on nine patients, found nine cases of cure, two of amelio-
 ration,  three failures, and one death.
   B. Operative Process.—A crucial or T incision lays bare the whole
 outer surface of the mastoid process; we then apply to it  either a
 perforator, or a small crown of the trephine, a drill or a trochar.  We
 take care to slightly incline the instrument forwards and  upwards in
 proportion as it penetrates.  As soon as  it  arrives  at the auditory
 cells we withdraw it, in order to enlarge the opening, if  it is neces-
 sary, before we stop.   Injections are then forced into it with caution.
 Tents, or rolls of lint, or a leaden sound, should be placed  daily in the
 perforation until the cavity of the tympanum is restored to its natural
 state.   The  chisel, gouge and  mallet,  which were  used by  J.  L.
 Petit, Chopart and Desault, ought to have  the preference, if the bone
 should be extensively necrosed and it were necessary to remove from it
 large sized fragments.  Should  nothing beforehand indicate where
 the instrument ought to be applied, it should be inserted at six  or
 eight lines above the point of the process.   The largest cells corres-
 pond to this part.  The auricular artery, which is found in front, and
 the submastoid artery, which is below, may be easily avoided.

           § III.—Catheterism of the Eustachian  Tube.

  A. The idea of penetrating  into the  cavity of  the  tympanum
 through the pharynx, is one that is already very ancient. Archigenes,
 Valsalva, Munnicks  and  Busson no doubt had this in their minds
 when they recommended  to  inhale vapors of water, tobacco,  or
 other substances,  and to  forcibly close  the  nose as well as  the
 mouth, in order to force them to pass towards the ear during expira-
 tion.  In  the  year 1724 Guyot, maitre de poste at Versailles, and
 Cleland in 1741, each devised an instrument for injecting the Eusta-
 chian tubes, the one by the mouth, the other through the nose.   The
sound of A. Petit, which is slightly curved, rendered the operation still
more easy.  Douglas and Wathen pronounced in favor  of the pro-
cess of Cleland.  Heuermann and Ten Haaf adopting that of Guyot,
introduced through the mouth into  the Eustachian tube a female
catheter above the velum palati, and afterwards  screwed  a small
syringe to the other  extremity of this  instrument.   Again recom-
mended by Falkenberg, Sims, Chopart and Desault, and by Callisen,
who sometimes performs it through the nose and sometimes through 
112
NEW ELEMENTS OF OPERATIVE  SURGERY.
 the mouth, and describes its steps very accurately, and by Buchanan,
 Itard, Boyer, Richerand, &c.;  and  proscribed  as  inapplicable to
 living man by B. Bell, and by Trempel as dangerous; these injec-
 tions have again been brought into repute and warmly extolled  by
 M. Deleau.  As a mechanical means they enable us  to clear out the
 tubes ; and as a medical remedy they act with efficacy on inflamma-
 tions and engorgements of every description, and on inspissated matters
 and collections of liquids in the cavity and guttural duct of the tym-
 panum.  It may be conceived then how important they would  be in
 deafness, which depends upon one of these causes.
   B. There is no doubt that we may penetrate into the tube through
 the mouth by means of a curved  sound above, behind and  upon one
 of the sides of the velum palati, as was  done by Heuermann ; but the
 operation being still more easy and especially more  certain through
 the nasal fossce, it is this route which, at the present day, is generally
 preferred.  Saissy''s instrument, Itard's sound in the shape of an Italic
 S, or a catheter, which  differs from a female  one in this only, that
 being open at its two  extremities, it has no apertures upon its sides,
 are with a  small syringe to force in the liquids, all that are required
 for such an  operation.  A gum-elastic catheter provided with its stilette
 and  properly curved ;  or a blunt-pointed probe in case it were requi-
 site to overcome the obstructions  with  a solid instrument, might in a
 case of necessity be substituted for the other catheters. ' The surgeon
 being placed on the side and in front of the patient, reverses the head
 with one hand,  seizes  with the other a catheter besmeared with some
 unctuous matter, presents  its  beak at the  orifice of the nose and
 causes it to slide along upon the floor of the nasal fossae at the lower
 part of the meatus, taking care to keep the convexity of the  instru-
 ment turned towards the side of the septum and slightly inclined up-
 wards.  Having arrived at the upper side of the velum, he  slightly
 elevates the extremity of  the instrument without permitting it  to
 leave the external wall  of the nostril, which obliges  it gradually to
 reach the upper part of the maxillary  meatus; continues to push it
 in this direction,  and  inevitably falls into the  pavilion of the tube,
 which from that point runs obliquely outwards, backwards and up-
 wards. As  soon as the catheter has entered sufficiently far, the syringe
 is adapted to its outer extremity, as when we wish to inject in hydro-
 cele, after which  any person may comprehend what  remains to be
 done.  The operation is repeated  once or twice  daily, and nothing
 prevents us, as is  perceived, from injecting  in  this manner into the
 middle part of the ear whatever medicated liquid  we  may  think
 proper.  Should the injection have stopped in the tube and be pre-
 vented by any means  from advancing farther, we should in this  case
 remove the syringe and introduce a blunt-pointed probe  up to the
 point where the difficulty is, in order to perforate or destroy it.  It
must be well understood here that force must not  be used but with a
great deal of caution, and that before having recourse to it we should
make ourselves certain that it has become indispensable and  that
better directed manipulations might not render it unnecssary.
  C. M. Deleau, perceiving that the point of the metallic catheter can-
not escape  from immediately butting against the walls of the tube, as
soon as we desire to advance it a few lines, that  its  inflexibility 
INTERNAL  EAR.
113
creates pain, and that  aqueous injections do not penetrate in this
manner into the auricular cavity but with considerable difficulty, has
proposed to substitute for it a flexible catheter, and to have recourse to
the douches  of atmospheric air already recommended  a long  time
since by Herhold, (L'Experience, 1.1., p. 518.)  By the processes of
this surgeon the operation becomes practicable at every age.  I have
seen at his residence two young boys, one four years of age, the other
seven, accommodate themselves in the readiest way that could be
desired to the  manipulations  of his  method, without evincing the
slightest indication of pain.  By means of a silver stilette four to six
inches long, having quite a strong  curvature near its extremity, and
a ring  on the other extremity, and  the diameter of which instrument
varies from half a line to a line and a half, he conducts a gum-elastic
catheter into the tube.  The patient being -seated upon a chair, holds
his head slightly reversed either  against the back of the chair  or
against a cushion for this purpose,  which supported upon an upright
may be elevated or depressed at pleasure.  The operator, armed
with the instrument, which has been previously oiled, presents it at
the nostril while holding it in his right hand, like a writing pen,  with
the concavity turned downwards and outwards.  Causing it to pene-
trate rapidly while following the floor of this cavity, he soon reaches
the velum palati, (which is indicated to him by an involuntary move-
ment of deglutition, and the extent of two inches or two inches and
a half, at which he has  entered,) and immediately elevates the beak
outwardly and  upward  by a circular or rotatory movement, in order
to enter into the tube.   Seizing with the thumb and forefinger of the
lefthand the free extremity of the catheter above, he endeavors, if it has
stopped, to make it advance, while the stilette is kept immovable by
means of his right hand;  proceeds in this manner till he reaches the
obstacle, which  he overcomes  in  the same manner that we would a
contraction  of  the urethra, and withdraws  the directing stilette  as
soon as he thinks he has entered  sufficiently far.  A silver pavilion
is  immediately screwed upon  the external opening  of the canula,
which  the  surgeon keeps in its place by means of a metallic wire
which  is passed around  it in the manner of a forceps, and which em-
braces at the same time the ala of the nose.  Adapting to this pavilion
the beak of a syringe, or bottle, or  ball of caoutchouc, he uses this to
force the air beyond  the obstruction, not exceeding a degree of pres-
sure which habit alone can enable him to estimate.   By applying our
ear to that of the patient, we perceive whether the cavity of the
tympanum is sound  or altered, empty or full, and whether the air
which we have forced into it can or cannot come out from it between the
catheter and walls of  the tube.   Substituting for the syringe the
pipe of a reservoir provided with a manometer, and in which a pump
does the duty of compressing the air, and then opening the faucet of
this apparatus, we establish in this manner a  double atmospheric cur-
rent in the ear, one which enters by the catheter, and the other which
issues out  between it and the  guttural duct;  the operator, who has
the power to augment or diminish  the force of this douche, intermits
it at the expiration of one or several minutes.
  D. In order to penetrate through the other nostril, the instrument
is  to be a little  more curved, with its beak slightly reversed in the
  vol.  in.                      15 
114
NEW ELEMENTS OF OPERATIVE  SURGERY.
 direction of its convexity.   Being held in the same hand, with the
 concavity turned downwards and inwards, it is made to pass along
 the inferior border of the septum.  Having arrived at the velum palati,
 the hand is elevated and carried outwards to incline the extremity of
 the instrument behind the vomer, that it may reach the tube.  The
 rest of the  process  is performed as in the preceding one.  In both
 cases, if the catheter is not properly in  its place, the patient himself
 notices  it when he has once undergone the operation.
   Its direction and the manner in which it  is maintained, moreover,
 sufficiently point it out to the surgeon.  He possesses however a
 ready means of satisfying himself with certainty.   Having with-
 drawn the stilette, we  have nothing  to do but to  force in the air or
 liquid by the canula.   The injection will fall into the  pharynx if the
 position  is false, and will not  penetrate, or, in  the contrary case, will
 enter into the cavity of the tympanum.   If after having  overcome
 the obstruction, the air produces  in  the cavity a pattering sound
 (bruit de pluie) upon the  membrane of the  tympanum, or a rough
 sound (bruit  sec), we conclude from this that the  middle part of the
 ear is not altered ; if it seems  rather to agitate a  liquid, and if the
 sound is mucose, (muqueux,) we are  then authorized in believing in
 the existence of pus, blood, serosity or at least an engorgement of
 the internal membrane of  the middle ear.
   In both cases, if the tube is evidently choked up or narrowed, and
 that the  patient perceives sounds better immediately after than before
 the catheterism, the deafness is imputable to the condition of the  tube
 and there is every reason  to  believe that it may be cured.   When
 there results no change from it, the disease is very probably  else-
 where, and we may be almost certain that this operation will be of
 no advantage afterwards.  If acute  pain be produced by the injec-
 tion, it indicates an acute phlegmasia or too great a degree of nerv-
ous irritability, which are to be treated by means of the usual reme-
 dies.  In simple obstruction or phlegmasias that are purely chronic,
 the suffering  is almost nothing  either during or after  the operation.
 M. Deleau explains the action of the air in a manner which is altoge-
 ther mechanical.   It ventilates, fumigates and washes out  gradually
 the cavity of the tympanum and  the mastoid  cells.  In  returning
 between the catheter and the  tube, it necessarily makes an effort, and
 becomes a dilating  and resolvent body by the compression which it
 exercises upon the engorged  tissues.   Water and liquids are much
 more liable to wound and  lacerate the membrana  tympani, &c, and
 do not produce medical effects different from gases.   Any intelligent
 person may understand after all that every case  must require  par-
 ticular modifications, and that in respect to the operative manual it is
 the same with contractions of the Eustachian tube  as with the coarc-
 tations of the urethra;  and that on this point, address and trials often
 repeated, joined to much prudence, will be  alone enabled to  give
 sufficient degree of dexterity  to the person who would desire  to em-
 ploy with advantage catheterism of the guttural duct of the auditory
 apparatus.
   E.  The  sounds,  catheters  and probes  devised by  M.  Gairal
 (Journ,  Hebdom.,  1836, t. II., pp. 97, 129, 197,) who provides them
 with  a  leather bottle  and faucet (une outre a robinet), and of  gum 
THE PAROTID, AND PAROTID TUMORS.
115
 elastic, in  order to inject the Eustachian tube, render tne operation
 still more  easy and perfect.
   F. One  doubt remains for me to express: the engorgement, thick-
 ening, and inflamed condition of the mucous membrane of the tube be-
 ing admitted as a cause of deafness, would it not be allowable to make
 use, against these affections, of the treatment which is advantageously
 employed  for  their  radical cure in the urethra, to wit: cauteriza-
 tion with nitrate of silver?  Having made no trial in support of this
 suggestion, I merely recur to it, en passant, and am not unaware of
 the apprehension that ought naturally to be inspired by the introduc-
 tion of caustics into the ear through the pharynx.
   I will add that the attempts made by different persons since the
 first edition of this work, have not yet produced any very satisfactory
 result, and that the excision of the tonsils is likewise a valuable means
•in the cure of this description of deafness.
                  PART  SECOND.

OPERATIONS WHICH ARE  PERFORMED UPON  THE NECK.
                        CHAPTER  I.

              TUMORS OF THE SALIVARY REGIONS.

        Article I.—The Parotid, and  Parotid Tumors.

                  § I.—Examination  of Facts.

  Should  we take literally what  authors  of the last century have
said of it,  nothing could be more simple than the total eradication of
the parotid gland.   In  our times, on the contrary, nothing seems to
be more uncommon, so much so that numerous distinguished surgeons,
Boyer among others, deny even its possibility.
  It is true that most of the cases which have been  related are far
from being conclusive.  Thus, as Richter had already remarked and
as Burns has demonstrated, the assertions of Heister, who says he
had often extirpated the parotid ; those of Scultetus,  Verdier, Palfin,
V. Swieten, Gooch, Berh, Roonhuysen, Gottefried, Errhart, &c, and
of Garengeot, who pretends that this operation  scarcely ever causes
any hemorrhage ; of Scharschmidt, who considers that  he has per-
formed it a great number of times  with success, among  others, upon
a patient in whom the tumor weighed three pounds ; of Acrel, who
was enabled to arrest the  hemorrhage by means  of  simple tampon-
ing ;  of Burgraw and Hezel, and of Alix, who was enabled to extir-
pate a mass of four pounds in weight below the ear, without produ-
cing  the slightest  effusion of  blood ; of  K. Boerhaave,  and some
others still, evidently refer to  the  ablation of lymphatic tumors de-
veloped in the depth of the  parotid space, or to cysts either salivary, 
116
NEW ELEMENTS OF OPERATIVE SURGERY.
as in the  case of M. Krimer, (Bull, de Fir., t. XVI., p. 72,) or pure-
ly serous, as  in  the  patient of M. Henri, (Bull, de TAcad. Roy. de
Med., 1.1., p. 56,) and not to the parotid itself.  M. Smith, (Gaz. Med.,
1839, p. 43,) who considers that he extirpated the parotid, in remo-
ving from the parotid depression  a tumor of the size of a nut, and
who divided the facial nerve, took away probably only a degenerate
lymphatic mass.   The tumor of the  size of an orange, successfully
extirpated  by M. Goyrand, (Savournin, Lancette Franc, 1839, t. I.,
p. 14,) from the parotid region,  was not  the gland.  In another case
the same surgeon, (Lancette Franc, 1839, t.  I.,  p. 14,) removed  a
part of the parotid gland, and the submaxillary gland, together with
degenerated lymphatic ganglions.  The patient got well without any
unpleasant consequences.  It would be doubtless difficult to say whe-
ther the tumor successfully removed from the  parotid region  by M.
PI. Portal, (Clin. Chir., vol. I., p. 125.)  was rather of an encepha-*
loid than lymphatic nature; but certainly it was not the gland itself.  In
1781, J. B. Siebold supposed that he had removed the parotid entire,
because after the operation it could be readily seen that the digastric
and stylo-hyoid muscles, as well as the caiptid artery, were laid bare.
In a student  mentioned by Heister, it  became necessary to go  so
deep,  that the  carotid gave rise to a fatal hemorrhage.  Soucramp,
supposing that he was about to remove a loupe, discovered that he
had extirpated the parotid.  There was much less blood discharged
than the surgeon expected, and the patient  was  perfectly restored.
In 1796, Ch. G. Siebold, who removed an enormous tumor from  the
side of the neck  in a young girl, states that the cavity thereby made
was so deep that all the assistants were obliged  to  admit  that  the
parotid had been extracted from it entire.  In  the patient operated
upon by Klein (Graefe und Walther's Journ., vol. I., p. 106) in 1820,
the facial nerve was  divided.  The cure was accomplished at the ex-
piration of eighteen  days.  In the case  of M. Idrac, there was no
artery requiring  a ligature ; but the wound presented the  same  as-
pect as in the patient  of Siebold the father.  The case recovered with-
out being followed by paralysis.  The  case of M. Lacoste  differs
from that of M.  Idrac in this only, that there was an abundant he-
morrhage, which was twice renewed, and  placed the life of the pa-
tient in jeopardy.  One of the tumors removed by M. Prieger, (Ibid.,
vol. III., p. 455,) weighed  nearly three  pounds.  The carotid was
avoided and the  woman survived.  If we may believe M. Kirby, he
was enabled to satisfy himself, after his operation, that the  interval
between the pterygoid  muscles was void, and  the  auditory passage
laid bare, as well as the temporo-maxillary articulation, and the  whole
length of the styloid  process.  Nevertheless, tamponing with sponges
succeeded in arresting the hemorrhage, and notwithstanding an ery-
sipelas which appeared on the  face, the patient recovered.   As to
the fact related by M. Pamard,"the author  himself admits that the
parotid was not  extirpated in its totality.   M. Naegele, on his part,
alleges that we  may remove this gland  in the dead  body without
wounding the facial nerve, and maintains that  he  performed it with
success without producing paralysis.   M.  Moulinie", (Bull. Med. de
Bordeaux, 1833,) having  cauterized after having excised or extirpa-
ted the tumor, lost one of his patients and cured the other.  In a pa- 
THE PAROTID, AND  PAROTID TUMORS.
117
tient whom I have seen and who was first successfully operated on
by M. L'Herminier of Guadaloupe, the cancer reappeared  and caused
death.  Goodlad furnishes a case which is sufficiently well detailed,
of extirpation of the parotid;  it is to Beclard, however, that we are
indebted for the  first demonstration of this fact.  His patient, who
was operated upon in 1823, had all the muscles upon  one side of his
face paralyzed, and as he  died some months subsequently, they were
enabled to ascertain that the whole gland had been actually extirpa-
ted.  A patient operated upon in September, 1824, by M.  Gensoul,
and who died in the course of the year 1825, also furnished the proof
that the parotid had been thoroughly extirpated.  M. Gensoul, still
more fortunate than in his first case, repeated this operation in 1826
with entire success; but the patient remained paralyzed on one half
of his face. M. Carmichael had been equally fortunate some time be-
fore, that  is to say in  1818, and  mentions the same peculiarity as M.
Gensoul as the consequence of the operation.
  In 1826, also, M. Lisfranc had occasion to remove the parotid, and
ascertained, after death, that scarcely anything of the gland remained
in the parotid space.   M. Mott, (Arch.  Gen. de Med., t. XXX., p.
419,) who previously tied the carotid, also considers that he extirpated
the whole  gland in a patient, who died  at the  expiration  of seven
weeks.   M. Roux (Ibid., 2e serie, t. VII., p. 404,)  and M. Chelius
(Ibid., 2e  serie, t. IX., pp. 230, 265,) in performing the same opera-
tion did not find  it necessary to tie the carotid artery.  In the ope-
ration performed  by  M. Heyfelder, (Graefe  und Waliher's Journ.,
vol. X., p.  575,) in the month of June, 1825, the patient lost but three
or four  ounces of blood, a small lobe  of  the gland only  was left in
front, and  the paralysis of the face ultimately disappeared sponta-
neously.   In the patient operated  upon by M. MacLellan in 1826,
the  cure was complete, says the author, though  the gland had been
entirely removed.  That  of  M.  Cordes,  (Journ. de  Walther, &c,
vol. II.,  p.  105,) who states  that  he did  not  leave the least particle
of the gland,  also perfectly recovered.   M. Bernt (Bull,  de Fer.,
t. III., p. 287,) also alleges that  he has  performed this  extirpation
with success.   The Archives (Arch. Gen. de  Med., t. IV., p. 64,)
contain  another example, in which layer after layer was  removed
down to the carotid.  In the operation which M. A. Fonthein (Graefe
und Waliher's Journ., vol. XIII., p. 290,)  performed  in  the  month
of November, 1828, the carotid was not  wounded, no hemorrhage
supervened, and the cure was completed on the  thirtieth  day. The
paralysis itself, which took place at first as in the preceding cases,
completely  disappeared.   In  the  month  of January, 1829,  M. A.
Magri  (Bull,  de  Fir., t.  XXII.,  p. 84, and  Journ. des Progres,
2e ser., t.  I., p. 261,)  extirpated on the side of the neck  a tumor
which included the whole of  the  parotid,  and was enabled  to dis-
pense with a ligature on the trunk of the carotid.  The patient was
restored in the space of twenty-six days, with the exception, how-
ever, of the facial paralysis which remained.  M. Dugied, who gives
an extract from most of these cases, and which are mentioned  also
by MM. Hourman and  Pillet  in  their  dissertation, also  states  that
MM. A. Cooper and Weinhold have repeatedly extirpated  the pa-
rotid entire.  But I  have not been able  to  ascertain where these 
118          NEW ELEMENTS OF OPERATIVE  SURGERY.
observations  have been published, with  the  exception of those of
M. Weinhold, (Bull, de Fer., t. VI., p. 242,) who has preserved one
of these glands in his museum and shows it to those who wish to see
it.  To the examples above mentioned it  would be necessary at the
present time to add the following:
   1st.  Man, forty-six years of age ; extirpation without previous liga-
ture ; no serious, hemorrhage ; cure ;  palsy of the face ; (Hendriks.)
2nd.  Woman, nineteen vears of age; extirpation without previous
ligature; cure; palsy of the face; (Hendriks.)  3d.  Woman, thirty-
eight years  of age ; extirpation without previous  ligature ; cure;
(Hendriks.)    4th. Woman, thirty-three  years  of age; extirpation
and cauterization ; cure ; (Hendriks.)—(Baamberg, Dissert, sur VEx-
tirp. de la Parot.)   5th. A woman ; size of a goose egg ; extirpation ;
cure; (Eulenberg;)  (Journ. des Conn.  Mid-Chir., t. III.,  p. 75.)
6th.  Another; enormous; previous ligature of the carotid;  (Sted-
mann;) (Gaz.  Med., 1832, p. 529.)  7th. Another; prolonging itself
upon the jaw ; ligature of the carotid ; cure ;  (Awll;) (Western and
Physic. Journ., vol. I., p. 423.)   8th. Another : (Eckstrum ;) (Bull.
de Fir., t. VIII., p. 204.)   9th. Another; boy, aged fifteen  years;
ligature upon the external  carotid ; apprehension of a return.   10th.
Another ; extirpation incomplete ;  (Ansiaux ;) (Clin. Chir., p. 233,
2d edit.)  11th.  Another; extirpation without previous ligature, and
cure ; (Warren, the father.)  12th. Another; the carotid wounded
and tied ; fistula and paralysis ; (Warren, the son;) (On Tumors, &,c.
p. 280.)  13th. A woman; thirty-four years  of age; on the right
side, and weighed twenty-one ounces ; performed 26th May ;  cured,
14th July, 1838 ;  (MacGregor ;)  (Lancet,  June, 1838, p.  498.)
14th.   Another ; the jugular [wounded] and  external carotid tied ;
cured;  (Widmer;)  (L'Experience, t.  II., p. 336.)
  II. Appreciation of the Facts.—The question whether we  may or
may not extirpate the parotid gland in its totality, appears to me to
have been incorrectly stated.  The salivary  glands, including with
them the parotid, scarcely ever degenerate.   The tumors  that have
been removed under their name almost all belong to other tissues and
to other organs.   Even  in the substance  of the parotid itself there
are a great number of lymphatic ganglions.   These  ganglions when
they swell become fungous,  tuberculous, and  cancerous, and are
transformed into bosselated tumors, which spread  out, flatten, and
disorganize the glandular  tissue, and lead to misconceptions of the
real character of the parts which are extirpated.  I have  performed
extirpations of this kind at least twenty times, to such extent as to lay
bare the whole parotid cavity, and to  be afterwards under the neces-
sity of submitting the tumor to a careful dissection, in order to satisfy
myself that the ganglions, rather than the glands, had been the source
of the disease.  I have, moreover, encountered  in this  region meli-
ceromatous, lipomatous, fibrous, melanotic, encephaloid,  and other
tumors.  A new-born infant that M.  P. Dubois  showed me, in Jan.,
1839, had in this part an erectile venous  tumor of five inches in
diameter.  Not wishing to treat in  this place except of tumors which
implicate the parotid, whether they originate or not from its  tissue,
I refer to the chapter on tumors in general for those of other descrip-
tions. 
THE PAROTID, AND  PAROTID TUMORS.
119
                  § III.—Anatomical Remarks.

  The parotid, enveloped in its aponeurosis, continuous in some res-
pects with the sub-maxillary gland, as it passes upon the internal side
of the angle of the jaw, united superiorly in quite a firm manner to the
auditory passage and behind to the mastoid process and sterno-mastoid
muscle, is prolonged in front upon the external surface of the masseter.
On its  anterior surface  it  covers or includes among its lobes from
above downwards and  from without inwards ;—1st, the transverse
facial artery and the two principal branches of the facial nerve at the
point where they  pass upon the border of the jaw; 2d, parallel to
this border the superficial temporal artery and  vein ;  3d, the external
carotid and the origin of the internal maxillary artery ; and 4th, the
pterygoid muscles and some branches of the pharyngeal vessels.   In-
feriorly it rests against the  stylo-maxillary ligament and the digastric
and stylo-hyoid muscles ; posteriorly between the ear and mastoid pro-
cess against the auricular artery; and deeper still upon the stylo-mastoid
artery.  At its apex it reaches nearly to the internal jugular vein, and
the great hypo-glossus, pneumo-gastric, and great sympathetic nerves,
between the transverse process of the first vertebrae and the pharynx.
One of its branches is almost always prolonged between the two caro-
tids.  Another frequently reaches between the stylo-glossus and sty-
lopharyngeal  muscles, the internal  carotid artery and the jugular
vein.  All of  them cover the styloid process, which they embrace,
and  the root  of the anatomical  bouquet of Riolan.  Finally,  it is
traversed obliquely from above downwards, from within outwards,
and  from behind  forwards, by the trunk of the facial nerve, which
bifurcates in its substance, where is  encountered also the vein which
makes the communication between the two jugulars, some very small
lymphatic ganglions, and other arterial and venous  branches much
less important.
                   § IV.—Operative Process.

  When the operation is decided upon, the first question which pre-
sents  itself, is this : should we or should we not imitate Goodlad, who
was  among the first that  tied,  as a preliminary step, the carotid
artery ?  In the beginning we never  can know whether we shall be
under the necessity of removing the gland in its totality.  Though
the wounding of the external carotid is  almost inevitable, the internal
carotid may in a great many instances be respected.   In making up
our minds  to surround the trunk only  with a thread during the pro-
gress  of the operation, as was  done or appears  to have been done
by Beclard  and MM. Carmichael, Gensoul and Lisfranc, we have,
if it  is practicable, the chance at  least of dispensing with the liga-
ture, and without exposing ourselves  on that account to the encoun-
ter of more serious difficulties than by any other process.  The-sur-
geon finding that the glandular tissue  instead of having produced the
disease has  merely become the  receptacle of it, endeavors  to  re-
move  the  gland  only  in  the  manner of cellular tissue,  which
surrounds or is in  the vicinity of any tumor whatever; it is to the
lympathic or cancerous tumor, and their branches wherever they may
be, that he directs his attention, in  place of following out the  pro-
• 
120
NEW ELEMENTS OF OPERATIVE SURGERY.
 longations of the parotid  gland.  Setting out upon this principle, I
 have never  been under the necessity of tying the carotid vessels be-
 forehand, though I had penetrated down to the bottom of the parotid
 cavity.
   A. Extirpation.—The  instruments that we may require for ex-
 tirpating  parotid tumors,  are composed of a straight, convex, and
 blunt-pointed  bistoury, straight  and  curved scissors, a  dissecting
 forceps,  a canulated sound  without any cul de  sac, a scalpel, the
 flattened  handle of which may serve  to  separate  the parts, should
 occasion require, needles  armed with ligatures,  and whatever  it
 would be requisite to  have  at  hand, if we were  obliged  to place a
 ligature  upon  the carotid  artery.   The rest of the articles consists
 of sponges,  small  balls and plumasseau  of lint,  agaric, long and
 square compresses, one or two  bandages, and  other  articles which
 are required in all  great operations.
  I.  First stage.—The patient being placed upon his sound side and
 held by assistants, is to be  fixed  in such manner as  to be enabled to
 breathe and  spit freely.  One of the assistants should hold himself
 ready to compress the trunk of the  primitive carotid in case of acci-
 dent.  The  size and form of the tumor, and condition  of the integu-
 ments, determine the kind of incision which is to be first made.   If
the skin is sound and free  from  adhesion, if the body to be removed
does  not exceed the dimensions of a  pullet's egg,  the crucial or T
incision might  be  replaced by the semilunar, to which for myself I
give  the  preference.   Otherwise we  must have  recourse to  the
elliptic incision, in  order to remove with the tumor a  flap of cuta-
neous tissue  of greater or lesser extent.  In this last case nothing pre-
vents us from making afterwards upon each lip of the ellipse another
incision, which  transforms  it into a legitimate T, and which after the
operation will reduce the whole to a  crucial incision.  Unless the
disease should have extended to a great distance towards the mouth,
there can be no doubt that there  is  less advantage in placing the
great diameter of the  wound  transversely, as Goodlad did, and M.
Fonthein advises, than from above downwards.   These are the only
general rules that  are  required  to  be  laid down on this first point.
It is  upon himself and upon his personal knowledge  and skill that the
operator will be obliged  to rely, in  order to follow them out,  or
to modify or restrain them.
  II. Second stage.—The  integuments having been dissected, and the
flaps reversed, the surgeon detaches the altered mass by commencing
at its superior part, then going  to its posterior border, in order that
he may not at the beginning fall upon the carotid ;  he ties the arteries
in proportion as they are opened, or if they are of little size confines
himself to their compression by the finger of an assistant,  and takes
care when he  reaches  towards the border of the  jaw or near the
pterygoid muscles, to hold the  cutting edge of his bistoury rather
turned backwards than forwards, and directed rather against the tis-
sues  to be extirpated, than towards  those which*are to be preserved.
 The   handle of the  scalpel ought to be preferred so long as  it
 appears  to  answer.  By  means of this instrument we detach  or
isolate the most of the  lobes of the gland or tumor, disengage them
 from among the vessels without incurring  the  risk of opening the 
THE PAROTID, AND PAROTID TUMORS.
121
arteries, and thereby diminish to the same extent the danger of the
operation.   When, however, we are satisfied that the adhesions to be
destroyed do not include any part which it is important to preserve,
the bistoury should be substituted  for the scalpel.  By tearing out
the lobes the dissection  is more safe ; by incision it is less painful,
and more favorable for the subsequent symptoms.
  III.  Third stage.—Having  arrived  behind the maxillary branch,
the operator should  double his precautions.   There are to be found
the external carotid  and the origin  of the temporal and  internal
maxillary arteries.  Deeper still at the top of the parotid fossa, should
there exist some pedicle  or  prolongation, which cannot be detached
by  the  handle  of the  instrument, prudence suggests that we should
apply the ligature to them on the side towards the sound parts, before
excising them.  On the supposition, that during all these manipulations
a large artery, the external carotid for  example, has  been opened
into, or that we perceive that its lesion is inevitable, we ought, before
going any farther, to lay it  bare near its root, in order that we may
apply the ligature to it sufficiently  low down not to incur the risk
of wounding it afterwards.  Should not the muscles of the styloid
process, nor  especially the digastric be degenerated, we  should  do
all in our power to avoid destroying them.  Under opposite circum-
stances we should sacrifice them without any hesitation, as well as the
trunk of the facial nerve, which it is useless to attempt  to save when
the whole  parotid is disorganized.   Finally, it may be possible that
the tumor no longer  resists except at its summit, and that  in spite of
the tractions made upon it by the left hand on the  one part, and
by the handle of the scalpel on the other, this  point adheres firmly
to the  bottom  of the wound.   In this case,  from the  apprehension
that it may include some  large vascular trunk, it is better to embrace
it with  a  ligature, strangulate  it in the same  way  that  we would
a polypus, in conforming to the advice of Hezel, and to restrict our-
selves for the time being, to the excision of that portion of the tumor
only, which remains perfectly free.  M. Begin, (Elem. de Pathol.,
&c, t. I., 2d edit., p. 204,) from having on one occasion  neglected
to adopt this precaution, found a volume of arterial spouting from the
wound, which gave him so much the greater uneasiness, from the re-
tracted end of the vessel  having escaped from the ligatures, and from
the necessity to which he was  compelled of having recourse to a
methodical, severe and painful compression.
  IV.  Fourth stage.—The arteries which may have been wounded
are, besides  the  carotid, the transverse facial, temporal, auricular,
mastoid, stylo-mastoid, occipital, internal maxillary, the inferior pha-
ryngeal, and even the lingual and facial.   All these branches there-
fore are to be successively tied, if we have not performed  this opera-
tion upon their common trunk at first.  The blood which continues
to flow afterwards can come only from veins, and requires, if it does
not stop of itself, no other means than tamponing.  At the first aspect
the excavation  which has been  produced has something frightful in
its appearance; but  its depth  alone would not prove that we had in
reality extirpated the parotid rather than the lymphatic  ganglions.
If the wound should only be some inches in extent, its flaps could be
approximated and united either by strips of adhesive  plaster or the
   vol. in.                      16 
122
NEW ELEMENTS OF OPERATIVE  SURGERY.
suture.   But when it is very large, if we attempt immediate and com-
plete union, we incur the risk of purulent collections, and simple or
phlegmonous erysipelas, and all their consequences, as we have seen
in the cases  ascribed to Beclard and many others.  After  the cica-
trization the patient may remain feeble, which he should be  apprized
of.   The movements of  the pharynx, larynx, tongue,  and  even the
jaw, sometimes suffer much from this operation, owing to the muscles
which have been divided.  More  frequently still,  the section of the
facial nerve more or less completely paralyzes the eyelids, ala of the
nose, the labial angle, or all the corresponding half of the face.
  B.  Ligature.—The cutting instrument is not the only remedy that
has been suggested to practitioners for the removal of parotid tumors.
Roonhuysen, who,  deterred  by the  dangers of  hemorrhage, had
already proposed to substitute the ligature  for it, introduced  a double
ligature  deep down  through the base of the  tumor,  and afterwards
tied its  two extremities  separately, the one above, the other below,
in such manner as  to  produce mortification  of the diseased tissues.
M. Mayor recommends that we should first lay  it bare as in extirpating
it, and that after having isolated all that portion of it which projects
externally, we should  traverse it  in the manner of Roonhuysen, or
better still, that we should draw it to the outside as much as possible
by means of an erigne forceps, and  then  introduce upon its root a
strong ligature, which he tightens  by degrees with his chaplet con-
strictor.  In five or six days, says he,  the degenerescence is entirely
cut through or reduced to putrilage, and no artery has run  any risk
of being wounded.   It was in this manner that he cured a young
girl fourteen years of age of a tumor that she had had for three years
in front of the ear; also another patient of eighteen, in whom the gland
extended from the zygomatic arch to below the angle of the jaw;
finally, a third, in whom the morbid mass, eight inches long and four
broad, was situated in the parotid region.   But whatever the author
may say on the subject, these facts relate much more to the extirpa-
tion of  degenerate lymphatic  ganglions than to that of the parotid
gland, properly so called.  I find, moreover, an inconvenience in this
method: it incurs the risk of removing only a part of the disease
when it extends deep within, while,  if it is superficial, the employment
of the bistoury being then less dangerous, the  ligature loses much of
its importance.  Nevertheless I would not  object to make trial of it
by combining  it with dissection in the  first  of  these cases.  Without
giving ourselves the trouble  of tearing out all the branches of the
gland successively, when they penetrate too  deep into the midst of
the  vessels,  a strong  ligature, which would  comprehend them  en
masse, and which would  enable  us to strangulate them by degrees,
appears to me to offer a resource which up to the present time, as M.
Mayor justly complains, has been too much  neglected.
  C.  Caustics.—The recommendation of Desault and Chopart, who
proposed, after having  excised all the  projecting portion of the scir-
rhus, that we should destroy the remainder with a hot iron or caustics,
is assuredly a much more objectionable process, and scarcely deserves
to be taken into consideration.  The  actual  cautery could only be
useful in this operation for obliterating  the mouths of vessels that had
escaped from the ligatures, and for  destroying some morbid vestiges, 
THE PAROTID, AND  PAROTID  TUMORS.
123
if there are any, that the instrument has not removed, contrary to the
intention of the operator.   (See on the subject  of  cysts or other
tumors of the parotid region, and the operations  required for them
the chapter on  Tumors in general.)

[Case of Extirpation of the Parotid Gland. By Valentine Mott,
  M.D.,  &c. &c.   (See American Journal of the Medical Sciences
  1832, Vol. X., pp. 17-20.)

  J. B., a native of St. Domingo, aged twenty-one  years, came under
my care  in the latter part of June for a tumor situated on the face.
He stated that he first observed it in January last, shortly after a se-
vere attack of fever, and that it gradually increased in size until a
few months ago, when  he became alarmed at  its progress,  and
decided upon visiting this country.
  Upon  inspection I found a very hard tumor, about the size of an
ordinary fist, involving nearly the whole left side of the face, and evi-
dently formed of the parotid gland, apparently in  a scirrhous state.
(See Fig. 1.)  From its magnitude, and as the only chance left for the
                             (Fig. l.)
recovery of my patient, I resolved upon attempting its extirpation, and
with his free  consent, after rendering the subject  perfectly  intelli-
gible to him, fixed on the 13th of July for carrying it into effect.
  Accordingly, on that day the  operation was performed.   It was
commenced  by  interrupting the  circulation through  the external
carotid artery by ligature, and for that purpose an incision was made
from the posterior angle of the lower  jaw downward and inward 
124
NEW ELEMENTS  OF OPERATIVE SURGERY.
 about three inches in length, so as to expose to view the inner mar-
 gin of the sterno-cleido mastoid muscle.  An enlarged  lymphatic
 gland was now exposed, lying directly upon the sheath of the ves-
 sels. Upon turning it to the inside, the external carotid was laid bare,
 and tied immediately below the digastric  muscle, and a little above
 the upper border of the thyroid cartilage.   From the tumefaction of
 this part of the neck the artery was nearly three inches  from the
 surface.
   An incision was next commenced above the jugum temporale and
 carried downward in a semicircular direction, until it terminated
 upon the os occipitis.  The incision in  the neck was now extended
 upward, to intersect the one over the  tumor.
   On detaching the integuments in the form  of a double flap from
 over the diseased mass, its black appearance removed the impression
 of its scirrhous character, and fully demonstrated a melanotic condi-
 tion of the gland.   I however determined upon continuing  the dis-
 section, and proceeded  to  detach it from  its various  connexions.
 With this intention I commenced by dividing along the inner margin
 of the tumor the adipose and cellular tissue, until the inner edge  of
 the  masseter muscle was exposed to view.   The  finger  was now
 introduced into the  mouth, and cut upon  in order to avoid dividing
 its membrane, and after separating the tumor for some distance from
 the  masseter, to which it  closely adhered,  I detached  it  from the
 jugum, which had become more or less carious from pressure.   It
 was next dissected from the mastoid and digastric muscles, and from
 the  posterior angle  of the  jaw, but as the patient  complained of
 excruciating torture when the tumor was raised from below upward,
 I determined to continue the dissection  from above downward, and
 accordingly separated it, with a few rapid  strokes of the knife, from
 the capsular ligament of the lower jaw, and removed the bulk of the
 disease, as represented in Fig. 2, next page.  The portion filling up the
 space between the  styloid  and mastoid  processes was cautiously
 detached with the  handle of a scalpel,  and  the facial nerve or portio
 dura divided by a  quick movement of  the knife.  At the instant of
 the division of this nerve, he seemed to evince more pain than at any
 period of the operation.   The  muscles of the  left side  of the face
 were paralyzed.  All the remaining portions of the disease were, as
 far as practicable,  removed.
   Several arteries  were tied during the extirpation of the tumor, and
 after its removal.   The trunk of the temporal was cut as it emerged
 from the disease, and yielded a profuse retrograde hemorrhage.
   The operation lasted about an hour,  and  the patient lost perhaps a
 pint of  blood.  In the  operation  I was  assisted  by Drs. Vache,
 Wilkes, Hosack, and Dykers, and it was performed  in the  presence
 of Drs. Barrow, A. Smith, Graham, and Seaman, and about twenty
 pupils.
   After waiting a  proper time, to see  if any bleeding would occur,
 and refreshing our patient, although he did not  seem exhausted, the
 wound was closed  by several sutures  and  adhesive straps,  and lint,
 compress, and double-headed roller, completed the dressings.
  Evening.—Has had a little sleep and feels  as well as he expected.
No hemorrhage; reaction has come on;  took claret and water, with 
THE  PAROTID, AND PAROTID TUMORS.
125
                            (Fig. 2.)

toast, which  he sat up  and ate with  a relish,  shortly after  the
operation.
  14^, morning.—Left two pupils with  him during the night, who
report that he had slept well, and did not take the morphine that was
directed, if he should be restless and in much pain.  Pulse 94—skin
natural.  As  he was averse to taking  tea or barley-water, from the
impression that it would occasion vomiting, he  was  allowed his
favorite drink of weak claret and water.
  Evening.   Has had no evacuation from his bowels;  directed the
nurse to administer a  common enema;  pulse 104; skin pleasant;
complains of  considerable pain in swallowing.
  15^, morning.—Enema  operated favorably.   Did not rest well
during the night, but in  the morning got some refreshing sleep.  Skin
a little heated;  pulse 122.
  Evening.   Says he is more comfortable every way.   Skin moist;
pulse 108 ; recommended an enema.
  IQth, morning.—Has had a very undisturbed sleep, and feels better
than at any time since  the operation.   Skin  soft;  pulse 96.   Takes
only sugar and water as a drink.
  Evening.   More comfortable than in the morning ;  has slept con-
siderably during the day.  Face more swelled ; pulse 100; skin cool
and soft; ordered an enema previous to bed-time.
  11th, morning.—Passed a pretty good  night; had a free perspira-
tion.  Pulse 98 ; skin natural. 
126
NEW ELEMENTS OF OPERATIVE SURGERY.
  Evening.   Feels in all respects better; pulse more frequent than
in the morning; skin the same.
  18th.   Swelling of the face rather diminished ;_does not complain
of any pain in the wound, or in his head; pulse 95.
  19th.   Some discharge from the lower part of the wound. Dressed
it; looks very well.  Pulse 88. Ordered chicken water and an enema
in the evening.
  20th.   Says he passed an excellent night, and feels much  better.
Pulse 96 ; skin natural; swelling of the face subsiding.
  21st.  Dressed the wound ; discharge very good ;  pulse 88.
  22d and 23d. Dressed the wound ; seems improving in all respects.
  24th.   Removed all the  plasters and dressed  the entire wound;
took away several of  the sutures; very much healed by adhesion.
Pulse and skin natural; bowels have been moved naturally.  Directed
more nourishment.
  21th.  Upon cleansing the wound, ligature from the carotid came
away.  Removed remaining  ligatures and sutures;  wound  mostly
healed;  at a small unhealed point, opposite the lobe of the ear, the
integuments appear to be taking on the melanotic aspect and a bloody
fluid is discharged.
  30^.  Wound  entirely healed, excepting at the point opposite the
ear, which has every appearance of a reproduction of the disease.
Complains of pain in the left knee, of which he has had several pre-
vious attacks.  Directed leeches and warm fomentations.
  August 5th.—Leeches have  been repeated, followed by blisters.
Pain in  the knee  less, but tumefaction increased; reunited portion of
the wound taking on  a melanoid fungous character; a small tumor
making  its appearance over the right eyebrow.  Ordered syrup of
sarsaparilla, with a small quantity of mur. hydr. in solution.
  12th.  Several tumors have made their appearance upon the scalp;
fungous of the wound  rather increased; a dark spot showing itself in
the integuments of the diseased  side of the face;  tumefaction of the
knee increased ;  complains of pain in the right side.  Skin assuming
a yellow color.
  20th.  Tumors  all increased in size ; hepatic affection very decided ;
confirmed hectic, and is evidently  sinking.   Every  thing done to
make him comfortable.
  3lst.  In all respects worse.   Permitted every thing he desires.
  Sept.  5th.—Died this morning.
  After death every exertion was made in order to obtain an  exami-
nation of the body, but such were the feelings of the friends  of the
deceased, that even the desire of passing a lancet into one of  the tu-
mors on the scalp, with a view of ascertaining  their positive charac-
ter, although I had no doubt of the case being constitutional melanosis,
was obstinately refused, and compelled to be abandoned.
  On dividing the tumor longitudinally, not a vestige of the original
organization of the gland could be observed.  The inner surfaces had
the appearance of firm tar, and  imparted a black  color to the  fingers
when touched.   V. Mott.]
   [Extirpation  of the Parotid.—M.  Larrey,  in the case of a girl
aged nineteen, in whom the chain of lymphatic glands on the left side
of the neck  became  so  hypertrophied as to constitute an enormous 
SUBMAXILLARY GLAND.                  12*7
tumor in that region, implicating the parotid, (L'Examinateur Medi-
cate, Aug. 15, 1841,) first effected a resolution of the  ganglia by the
actual  cautery,  moxas, mercurial frictions, &c, which treatment
occupied two years, and  then removed the parotid, when a perfect
cure resulted.  T.]

               Article II.—Submaxillary Gland.

                              §1.

  There is no conclusive proof to show that the sub-maxillary gland
has ever passed into the state of scirrhus  or cancer.  The examples
which  have  been  brought forward for this relate to  the conglobate
glands which are in its neighborhood, and which are  found between
them and the border of the jaw and  platysma-myoides muscle.  Its
induration, in consequence of  chronic inflammation, in grenouillette,
for example, is far from being as unfrequent.
  Abscesses that become developed in the cellular tissue of its neigh-
borhood, and which remain fistulous after being opened, also produce
this result.   But however obstinate it may be, this malady ordinarily
yields to other means than extirpation, which never seems to be abso-
lutely required.  Of the observations which have been published in
France, the one which I have  made known, and which belongs toM.
J. Cloquet, is a pure and perfect example  of extirpation  of the supra-
hyoid ganglions ; that of M. Amussat comes probably under the same
description, and moreover it is far from being demonstrated that in
his patient  the operation was absolutely necessary.  I would say the
same of the case related by  M. Warren, (on Tumors, &c, p. 129.)
It moreover appears to  me evident that  the tumor of the size of an
egg extirpated  by  M. Sicherer, (Gaz. Mid., 1838, p. 810,) under the
title of a maxillary gland, was nothing more than a lymphatic tumor.
Was not this the case also with the sub-maxillary cyst removed by M.
Malcolmson, and which I have spoken of elsewhere ? (see  Salivary
Cysts.)   The cases of extirpation of the sub-maxillary and sub-lingual
gland mentioned by M. Diday, (These de Concours, 1839,p. 59,) being
unaccompanied with any detail, are still less conclusive.  The tumor
of the size of an egg developed under the  angle of the jaw in an epi-
leptic, and extirpated by M. Petrunti with much difficulty, the opera-
tion causing frightful convulsions for the space of four days, (Gaz. Mid.,
1839, p.  122), was, as I conceive, only a lymphat:c  mass,  and  not
cancerous,  as the author supposes.  In this case  the disease did not
repuUulate  and  the epilepsy  disappeared.   In conclusion, whether
the disease  be seated in the gland or in the ganglions which surround
it, the operation when we have once decided on removing it is nearly
the  same.   The  sub-maxillary gland, embraced as it were inferiorly
by the concavity of the digastric muscle and separated  from the in-
teguments  by the  facial vein and platysma-myoides muscle, rests,
superiorly against the inner surface of the jaw, inwardly against the
hyoglossus muscle  and the  mylo-hyoid, upon the external surface of
which one of its prolongations extends.  The facial artery runs along
its upper  and inner side.  The  lingual nerve and the artery of the
same name pass below it.  Far above, it  receives the plexus of the
myloid nerve. 
128
NEW ELEMENTS OF OPERATIVE  SURGERY.
                    § II.—Operative Process.

  All that I have said of the form and direction  to  be given to the
incisions, in speaking of the parotid, is equally applicable  here.  The
patient is to have his mouth kept shut,  the chin raised up. and the
head  thrown back  and to one  side.   The  gland or tumor is thus
fully exposed.  In order to reach it, should the  semilunar or hori-
zontal incision  not  appear  to  answer, the surgeon divides the skin
first from  above downwards from the  border of the jaw  as far as to
the os hyoides,  and  afterwards transversely; he then dissects, sepa-
rates  and  reverses  the  flaps  thus circumscribed;  applies two  liga-
tures  upon the facial vein to divide it in the interval, should it inter-
fere too much  or cannot be kept out of the way by means  of a
hook; inserts an erigne into the body of the  gland  and  draws it out-
wards and upwards, and then backwards and  downwards, while  he
detaches from it, with short cuts of the bistoury, its inferior or ante-
rior half;  carefully avoids the lingual artery and its associate nerve ;
searches posteriorly for the trunk of the external maxillary artery
and ties it.; brings the erigne forwards and  downwards; separates
the morbid mass in  the  direction of the tongue, and then  removes it
without any  difficulty.   If we  should prefer commencing with a
ligature on the  maxillary artery, it would be necessary to direct the
first incision upon this vessel  and to search for it at the point which
I have mentioned in another  chapter.   Nor are we obliged to tie it
at all, if we take the precaution to preserve  intact up to  the end of
the operation that part of it  at which its  branches enter into the
gland, and  to embrace it as a pedicle by means of  a strong ligature.
For the dressing and  subsequent treatment we proceed in the  same
manner as  after the  extirpation of the parotid, bearing in mind, how-
ever,  that  below the jaw union  by the first intention  has infinitely
less danger, and that the totality of the operation is incomparably
less formidable than in the  sub-auricular notch.  I have  elsewhere
treated  in detail of this  operation, while speaking  of  lymphatic  sub-
maxillary and supra-hyoid tumors.
                        CHAPTER II.

              TUMORS OF THE SUB-HYOID REGION.

                Article I.—The Thyroid Body.

  Goitre, or bronchocele, is a tumor which has attracted much at-
tention in the present state of medical science, and which should not
be attacked by surgical means until after having unavailingly made
use of iodine, the powder of Sency, and  other pharmaceutical  re-
sources which have been much extolled in these latter times ;  also it
is requisite that the tumor  should  have sufficiently incommoded the
patient to jeopardize his life.  Serous, sanguineous and purulent cvsts. 
the thyroid body.
129
and vascular, erectile, fungous,  aneurismal, tuberculous, calcareous,
fibrous, schirrous, colloid, encephaloid, and viscous (gommeuses) tu-
mors, have been confounded with the hypertrophy of the thyroid tis-
sue under the  common  title of goitre.  The surgeon therefore will
not be enabled to undertake their cure with advantage until he shall
have ascertained their species, or until having consulted  the memoir
of M. Sacchi (Arch. Gin. de Med., ser. 11, t. II., p. 246,)  on this sub-
ject.   Caustics, employed at the time of Celsus, and since by a small
number of practitioners to destroy goitre, are no longer in use at the
present day.   The  steatoma which extended from the superior part
of the larynx down to  the  sternum, and  which was cauterized and
cured  by Pietsch, (Gaz. Salut., No. 34, p. 3, 1771,) was  it in reality
a goitre ?
                              §1.

   The seton,  which the elder Moreau, according to Burns, which
Gerard, and especially Flajani, made trial of or saw employed with
success,  and which MM. Maunoir and Quadri have  extolled as  a
new resource, is not obnoxious to the same objections.   The advan-
tages which may be derived from it have now  been indisputably es-
tablished by a multitude of authentic observations, and wherever, in
place of  a hypertrophy or fungous or cancerous degenerescence, the
tumor shall be found to consist of cysts and  liquid, or semi-liquid
substances, its application has every thing rational to recommend it.
Monro, moreover, is not its inventor.  Rogier, (P. Forest  dans Bo-
net, t. III., p. 67,) who  speaks of it as in common use, recommends
that we should insert two crosswise in place of one; also the rod of
red hot  iron passed through the tumor as  mentioned  by Blegny,
(Planque, Biblioth., t, V., p.  189, in 4to,) was it not a species of seton ?  ♦
M. Quadri generally inserts it from above downwards,  with an in-
strument similar to Boyer's  needle, and for fear of wounding the ves-
sels rarely carries it farther than half an inch deep.   However small
the mass to be destroyed may be, he introduces two, three, and even
four at different points.   The goitre soon commences to shrink, and
the resolution, which is effected by degrees, continues  to go on in
most  cases, even after  having  withdrawn the meche, and after the
wounds  have  cicatrized.   The thyroid gland  is frequently the seat
of an indurated enlargement.  I have seen those that were schirrous,
and Burns and M. Wardrop have found in them encephaloid matter
and fungus hematodes.   But the facts mentioned by the surgeon of
Naples, do not prove that the disease may be cured in such cases by
the seton.  The three cases which are related by M. O'Beirn, (Arch.
Gen. de Med., 2nd ser., t. VI., p. 415,) are not very conclusive.  M.
Nick, (Gaz. Med., 1835, p. 311,) who approves  of it, and who al-
leges  that by means of the seton M.  Klein has succeeded in six
cases out of seven ;  and M. C. Hutchinson in two out of three cases,
and M. Hauslentner also in two cases; has not been  enabled to
avert the censures which have been cast  upon  this method by Som-
merville  and Kennedy, (Gaz. Med.,  1837,  p.  311.)  It was with
cysts  that M. Addison  (Ibid., 1837, p. 25,) obtained the three suc-
cessful results that he  mentions, and the case cited  by M. Vado,
(These, No. 123, Paris, 1832,) also  does not relate to a  tumor of  a
   vol. m.                      17 
130
NEW ELEMENTS OF OPERATIVE  SURGERY.
bad character.  In severe cases  it has been proposed to apply the
ligature upon the bronchocele, to extirpate it or to ligate the princi-
pal arteries which enter into it.

                        § II.—Ligature.

   It is to Moreau, surgeon of the Hotel Dieu, that Valentin ascribes
the suggestion of attacking goitre  by the ligature.  One of the pa-
tients thus treated in  1779 was  not'cured, but the other recovered
perfectly.  The  tumor in the first was a  cancer, that of the se-
cond was of a fatty nature.  The surgeon inserted a double ligature
through  its base, as if for the purpose of dividing it into two equal
parts, which he afterwards strangulated separately.  Some years
subsequently, viz., in 1791, Desault also had recourse to it, but it was
for the purpose of terminating an extirpation, the last stage  of which
was attended with too much danger. Brunninghausen used it with en-
tire success in 1805, to destroy an enlargement of the size of an egg,
which was situated at  the fore part of the neck, between the larynx
and  sternum, in a young man 25 years of age.
   A child 12  years of age, operated upon by M. Mayor in  1821, for
a goitre of the size of an orange, was  discharged  from his hospital
perfectly cured at the expiration of a  month.  In  a  young man 21
years of age, the tumor occupied the front part and both sides of the
neck, and extended from the angles of the  jaw and  the  parotid re-
gion, as far down as to the sternum  and  clavicles.   Of the three
lobes of which it was composed, one, or that of the middle, equalled
in volume the head of a 7 or 8 months' foetus.   The entire  mass be-
low the jaw was nine inches in height and 26 in breadth.   The gen-
eral condition of the  patient was  bad, but  M.  Mayor nevertheless
effected a radical cure  in less than  two months !   Nor was he less
successful in a lady of Sackendorf, who had in vain consulted the most
distinguished  medical men  of all countries for the removal of a tumor,
which she had had for  the space of about thirty years.  This tumor,
which continued  to increase, occupied  the entire left side of the neck,
had pushed the larynx to the right, and appeared  seriously to  compro-
mise the life of the patient.  His process consists in laying  bare the
anterior surface of the  bronchocele, in  afterwards isolating it from
the subjacent parts by means of the  fingers or  the handle of the
scalpel,  and then applying a strong ligature upon the root of each of
its lobes, or traversing  its  base with a double ligature, which admits
of its being strangulated above and below.   In place of one or two
ligatures he sometimes  emplovs as  many as four, each one of which
is then made to include a fourth or third of the gland, and as may be
supposed, the chaplet constrictor is  the one to which  he accords the
preference.  From these details, nevertheless, it is evident that the liga-
ture here is but an auxiliary means, or a resource against hemorrhage,
when we are fearful of wounding some vessels  of importance ; and
that if we were sure of avoiding all the large arteries with  the bis-
toury, extirpation would be still far preferable.  It is an operation,
moreover, which is not unattended with danger;  and two of the pa-
tients operated upon by M. Mayor himself, perished.   It causes suf-
focation, extreme anguish and difficulty of respiration, and frequently 
THE THYROID BODY.
131
some of the symptoms of typhoid fever.   The soldier  of M. Malle,
(Thise de Concours, Strasbourg, 1836, p. 27,) created the greatest
degree of alarm in the mind of the operator.  Consequently I should
not recommend it. except the tumor is first detached  by means of
the cutting instrument or fingers to as great an extent as is possible,
in order that there may be a pedicle only instead of a large base to
be strangulated, and upon the condition also that the goitre  should
be promptly excised, external to the ligature,  and  not left to putrefy
in the wound.

                § III.—Obliteration of the Arteries.

   Some practitioners have supposed that by tying the thyroid arteries
we might probably obtain the resolution of the  goitre.   Burns as-
cribes the first suggestion of this practice to W. Blizard.  The pa-
tient operated upon by this surgeon did very well during the space
of a week; but repeated hemorrhages and hospital gangrene, which
soon exhausted him, ultimately caused his death.  Since that period,
viz., in  1814, M. Walther, who adopted  the precept  of the English
surgeon, performed the operation with entire success.  The same is
to be said also of M. Carlisle, and we are indebted to M. H. Coates
for another successful result.   M. Earle, M. Green,  and M. Chelius,
have been no less fortunate; and  M. Boileau being  compelled in
1825 to tie the carotid  for a  traumatic lesion,  had the satisfaction not
only to  save his patient but also to  cure him of a goitre, which had
troubled him for a long series of years.  M. S. Cooper, however, in-
forms us that a ligature upon the thyroid vessels, as performed by M.
Brodie,  produced no diminution  in the volume  of the  tumor.   It is
necessary also to add that M.  Langenbeck, having been obliged to
tie the two carotids after having tied the right superior thyroid artery
nine days before, saw his patient die on the  following day.  These
facts, though not very numerous, are nevertheless  sufficient to in-
duce us to submit a remedy of this  kind  to new trials.  We ought
especially to attempt it in pure and simple bronchocele or hypertrophy
of the thyroid body, and in all cases where the vascular system pre-
dominates in  the tumor.  Instead of one or  two, we should in my
opinion  tie the four thyroid arteries; otherwise it is to be feared that
the blood which is arrested upon one side, may come out again from
the other.   The operation after all, has nothing  in it formidable  to
the skilful surgeon.  If the natural pulsations of the vessels which
are to be laid bare are not sufficiently strong to serve as a guide for
the instrument, we must proceed to seek for each thyroid artery,
where they are given off from  the carotid for  the upper ones, and on
the inner border of this  trunk for the  lower, following  out  in other
respects the  rules elsewhere laid  down.

                        § IV.—Injections.

  If there should be a cyst, whether serous or sanguineous, irritating
injections,  as recommended by Rullier and others, might  have some
chance of success.  I would not recommend  them to be made with
chlorine, as has been suggested by M. Deconde, (Encyclog. des Sc. 
132          NEW ELEMENTS OF OPERATIVE SURGERY.
 Mid., 1836, p. 6,) but I would willingly make use of the solution of
 the tincture of iodine, in the same way as for  any other cyst.

                        § V.—Incisions.

   Having noticed that an enormous purulent  goitre which contained
 calcareous concretions,  and mention  of which  is  made by  Selhe,
 (Rougemont, Bibl. du Nord., p. 134,)  was cured by  making  an in-
 cision into its tumor; that  M. Beck (Arch.  Gen. de  Mid., 3e  ser.,
 t.  I., p. 319,) had succeeded in two out of three cases, by excising a
 part of the cyst; and that a thyroid cyst, which had suppurated, was
 also cured  by incision in the case of  M. Rey, (These, No. 79, Paris,
 1834,) and in that  of M. Laugier,   Diet, de Med., 2d  edit.,  t. IX.,
 p. 180;) I  have established a method (Bull, de Therap., t XL, p.
 344,) which still  better secures the success which has been obtained,
 by means of four incisions on as many different thyroid cysts,  by M.
 Petrali, (L'Experience, t. II., p. 173.)   I incise the tumor on four or
 six points of it,  according  to its volume, giving to each incision an
 inch in length.   By means  of the finger, here  introduced,  I  empty
 and cleanse the cyst; I then pass into  these wounds a meche of  rav-
 elled linen, which is to be moved in the manner of a seton during the
 space of four or five days, until the suppuration has  been perfectly
 established; I then withdraw them, and the  tumor from this  time
is  treated as an  abscess.  Three  patients  have been operated upon
 by me in this manner at the  hospital of La Charite, and another
 in private  practice.   The  disease in the  three  cases was  an enor-
 mous purulent goitre; two of these were cured in six weeks, and one
 died; the fourth case had a sanguineous cyst with thick walls, and
recovered.  Incision of thyroid tumors or cysts also is  far from being
always  exempt  from danger.   M. Begin, (Elem. de  Chirurg., 2d
 edit., p. 23,) being  desirous of incising a tumor of this  description,
 which rested upon the  trachea, cut  down upon a vascular areolar
mass, the extirpation of which  was impossible,  and the incision
into which, which had already caused repeated bleedings, might have
been followed by a fatal hemorrhage.   The operation was not com-
pleted, and the patient recovered, but retained his tumor.

                      § VI.—Extirpation.

   By means of extirpation we remove the totality of the disease, and
 the patient is promptly relieved of it; but it is  attended with  so many
 and such formidable  dangers, that the great  majority of authors, at
 the present time, agree in proscribing it.
   A. That, at the time of Albucasis, a patient who was submitted to
 this operation should have died of hemorrhage, has nothing in it very
 surprising;  that the young lady mentioned  by Palfin succumbed
 during the operation from the same cause, we may also readily  con-
 ceive ; though one of the patients cited by Gooch perished, exhausted
 at the end of eight days, and that in  order to save the other  it be-
 came necessary  that the assistants should relieve each other during
 the space of a week, in  order to compress without intermission, by
 means of their  fingers,  all  the arterial branches which had been 
THE THYROID BODY.
133
opened;  though  an officer, whose  history is given by  Percy, also
 Eerished  from hemorrhage, and  that the patient operated upon by
 )upuytren survived the ablation of the tumor but thirty-five hours;
though the  instances of extirpation of goitre adduced  by Freytag,
Theden,  Desault, Giraudi, Fodere, and the barber who, according to
Paradi, performed it successfully upon his wife, may not all of them
be very  satisfactory; and though the  young girl  treated  by Klein,
(Graefe  und Walther's Journ., vol. I., p. 120,) was seized with an
apoplectic fit and  perished  from  it,—we  should nevertheless be
wrong in censuring, in absolute terms, the  essays made to  render
us more  familiar  with this operation.   Peckel and Ravaton  (Petre-
quin, Bull, de Ther., t. XL, p. 344,) have performed it several times
with success, and Vogel (Bibl. Chir. du Nord., p.  391,)  has been no
less  fortunate.  M. Graefe, (Gaz. Med., 1835, p. 169,—Rufz, Arch.
Gin. de  Mid., 2e  ser., t. X., pp. 25,  41,—Graefe und Walther's
Journ., 1820,) who lost one  of  his patients, has cured  two  others.
M. Green (Lancet, 1829, vol. II., p. 351,) succeeded  in  extirpating
one  of the  lobes of  the gland,  and  M. Warren, (On Tumors, &c,
p. 305,) who tied the carotid, also saved  his patient.  That of M.
Roux  (Rufz, Arch. Gen. de Med.,2e s6r.,t. X., pp.  25, 41,) died after
the exph ation of a few days; but that of M. Voisin (Gaz. Mid., 1836,
p. 372,) recovered perfectly.
   The enormous tumor extirpated by M.  G. Bell, (Arch. Gen. de
Mid.,  t.  IX, p. 283,) soon repullulated.   But the cyst removed by M.
Gubian (Ibid., t. XII., p. 315,) did not reappear.   By combining ex-
tirpation with the ligature, as has been done by M. Mayor and M.
Hedenus, (Graefe und Walther's Journ., vol. II., p. 240,) there can
be no doubt that  in future some  successes might be obtained from it.
The most complicated cases  could not intimidate this last mentioned
surgeon,  who in 1822 could already enumerate six successful results
obtained  by him.   His process differs from that of M.  Mayor in this,
that he carefully  dissects  the bronchocele down to its  deep-seated
surface, and ties the arteries in proportion as they are divided by the
instrument; and  in this also, that with him  the ligature, which he
applies in other respects after the manner of the practitioner of
Lausanne, but which  he knots in the same manner as for obliterating
a large vessel, has no other object than to strangulate what he dare
not venture to divide, and to enable him to excise the entire morbid
mass immediately, with security.  For myself, however, I should not
decide upon extirpation of an actual goitre, until after having satis-
fied myself that there was not any co-existing lesion of the heart or
tendency  to apoplexy, and that  the  surrounding  lymphatic  glands
were sound ; and until after having made trial of either the seton in
the manner  of M. Quadri, the simple incision indicated by Fodere,
and  employed successfully by Delpech, or the  numerous incisions
which  I have recommended, or as Rullier advises, an irritating injec-
tion into  the  cyst, if  any  exists, or the previous ligature upon the
thyroid arteries;  and not  until after the pressing entreaties of the
patient, and  only in cases where  the bronchocele instead  of constitu-
ting only a  simple deformity, forms  a disease whose progress and
character threaten the life of the  individual.
  B. Operative Process.—We will suppose that  there exists a goitre 
134
NEW ELEMENTS OF OPERATIVE SURGERY.
which involves every portion of the  gland.  The preparations are
very nearly the same as for the removal of the parotid.  The patient
is placed upon his back, with the head gently reversed, and support-
ed by assistants.  The operator being situated  on the right side,
makes upon the median line a first incision, which commences above,
and is to finish  a little below the tumor ; transforms this wound into
a  crucial incision ;  detaches the flaps, and  dissects them down to
their base ; divides transversely the  fleshy  fibres which  he cannot
push aside, reverses them towards their attachment if they are sound,
or comprises them in the subsequent excisions if  they are diseased ;
ties such vessels as interfere with him ; reaches by degrees  the bor-
ders of the tumor, which he draws towards him while tearing rather
than cutting it out, and finds deep down,-at their superior and inferior
part, the four principal arteries of the organ, each of which he iso-
lates and  surrounds with a ligature.  Avoiding with care the trunk
of the carotids, the internal jugular,  the  descending branch of the
great hypoglossal nerve, the  pneumo-gastric, and the great sympa-
thetic  and the cardiac nerves, which are seen a little farther to the
outside, crossed by quite a  considerable number of secondary veins,
the surgeon then detaches the tumor at its upper part, from the sides
and  anterior face of the larynx,  from which it is separated only by
the thyro-hyoid muscles, cellular lamellae, and some small arteries
which must be  tied, and which  come  from the lingual or  maxillary
branches.  Returning towards its borders, which  he raises and sepa-
rates from the oesophagus or trachea,  near which  run the  laryngeal
nerves, he recognizes  when the tumor holds no longer, except by its
lower border, whether the venus plexus which issues from  it, and the
thyroid artery  of Neubauer, which very frequently enters  into it,
would make its complete separation  dangerous.   If so he includes
all these  objects  with a ligature, or  traverses  their pedicle with  a
double ligature, and strangulates them as powerfully, and as near
to their  root as possible,  after which he may excise without any
fear the totality  of the goitre.   So  laborious and  delicate a dis-
section  cannot  be rapid.   The  patient requires  to  be allowed to
repose from time to time, in order to  breathe.  All kind of pressure
upon the trachea or larynx  should be carefully avoided, and the sur-
geon should vigilantly bear  in mind that if the inspirations  are  not
free, the blood will be instantly seen to accumulate in the veins, and
to rush out in large quantities from the slightest cut of the bistoury.
   Before  proceeding  to the dressing, it is important that even  the
smallest  arteries  should be tied  or twisted.  As to the veins, they
will cease bleeding as soon as the patient  shall be free from  oppres-
sion and  be  enabled  to dilate  his chest freely  and without fear.
Should it be otherwise, the ligature must  be applied to them.   The
convulsive movements and  even death which have sometimes super-
vened, during  the extirpation of tumors connected with  a  great
development of the vascular system, might be  attributed  in this
region to the introduction of air into the veins, (see Volume I. ;)  M.
Boullay, (Gaz.  Mid.,  1839, p. 79,)  who saw a horse perish a few
minutes after bleeding the jugular for an attack of pneumonia, ascer-
tained that  the air had been introduced  in  large quantity into  the
heart and vessels ; but as I  have already said, it remains for the fact 
TUMORS  FOREIGN TO THE  THYROID BODY.
135
to be  demonstrated in all the cases of this kind which have been
related.   The surfaces being  thoroughly sponged and the ligatures
brought to the angles of the solution of continuity, nothing more re-
mains  to be done than to approximate the flaps of the wound and to
close it up more or less perfectly.   As in front of the neck the centre
of the division is more elevated than the sides, it cannot but be at-
tended with advantage in undertaking immediate reunion, either by
means of adhesive plasters or  even a few points of suture, provided
however that with the exception of a few ligatures we are not forced
to leave any foreign body under the skin.  The different portions of
dressing moreover should be light and gently applied.  All compres-
sion in such a region would be dangerous, and too great a number of
pieces of dressing would  cause an injurious accumulation of heat.
Should the tumor  involve only  one side  of the thyroid, or if
independent of this  gland this tumor should be on another  point of
the anterior half of  the neck,  the modifications which would require
to be made in the process which I have described are too unimpor-
tant and too easily anticipated to  make it necessary to point them
out in  detail.

     Article IV.—Tumors Foreign  to  the Thyroid Body.

   Synovial cysts, loupes  and lymphatic tumors, &c, may develop
themselves  in the neck as well as in any other region;  but having
treated of these in another chapter, it is  not my intention to notice
them again  in this place.   I have successfully removed an  athero-
matous cyst of the  size of a  large nut, which was situated in the
supra-sternal fossa of a young American, between the layers of the
fascia cervicalis ; I have seen lymphatic masses and aneurismal tumors
of the  aorta elevate themselves from behind the sternum as high up
as to the neighborhood of the  larynx ;  but it has not fallen to my lot
to effect the extirpation of  a degenerate  thymus, an operation men-
tioned  by M. Haugster, (Arch.  Gin. de Med., 2nd ser., t. III., pp. 109,
263.)   There is still another sort of tumor of the neck, viz: the em-
physematous, upon which 1  have only one word to say.  This tumor,
in the case of M. Ollivier, (Ibid., 1.1., p. 421,) which followed a sud-
den crepitation, was situated on the supra-sternal region; in the cases
of the  English physician, (Med. and Phys. Journ., June, 1833,) when
irritated by exertions it extended itself rather towards the face, and
in the case of M. Malle, (These de  Concours, Strasbourg, 1836,) or
M. Begin, (Elem. de Chirurg., &c, 2nd edit., t. II., p. 24,) it was occa-
sioned  by the extirpation of a  thyroid tumor.  It is a description of
tumor which is imputable to some laceration in the air passages, and
which  must be treated like any other emphysematous tumor 
136
NEW ELEMENTS  OF OPERATIVE SURGERY.
                        CHAPTER III.

                        AIR  PASSAGES.

                   Article I.—Bronchotomy.

  Under the name of bronchotomy, it is my intention to speak of the
artificial  and methodical opening of the air passage in its cervical
region, and not in that of the bronchi, as its etymology would lead
one to suppose.  At the present day, when it is performed on various
points of the respiratory tube, the word bronchotomy ought to be ap-
plied to the operation in  general, while  in its special applications it
Would comprehend  tracheotomy, laryngotomy  and laryngo.-trache-
otomy.  Asclepiades is the first, I  believe, who ventured to perform
it.  No one before Antylus and  Paul of Egina, had described it.
C. Aurelianus, Aretaeus and most of the Greek authors repel the very
mention of it;  and Rhazes advises it only in cases threatening imme-
diate death.   Though Albucasis, in order to prove that the divided
cartilages will reunite, cites a young girl  who  had cut her throat
and who perfectly recovered; that Avenzoar made with the same
object  some successful experiments upon goats, it is  not  until  we
arrive to the year 1543, that we find this operation again revived by
M. Brassavole.   It is only since the time  of F. ab Aquapendente, that
all writers have  admitted its utility,  and even  its necessity under
certain circumstances.   It is far from being the fact, however, that
opinions  have  always  been unanimous  upon the cases which  re-
quired it.

              § I.—Indications and Appreciation.

  A. P. d'Abano, who  calls  it subscannation, and after  him  Gherli
of Modena, G. Martine, &c, consider  bronchotomy  indicated in all
cases of tonsillary or laryngeal angina, which threaten the suffocation
of the patient; but, though advocated by Mead and Louis, their opi-
nion, which goes back  moreover as far as to the time  of Avicenna,
and which has been zealously opposed by Cheyne, is at the present
day scarcely sanctioned except by Baillie and Fare.  Anginas that
are purely inflammatory, however intense they may be, rarely make
it necessary to have recourse to a remedy of this kind.   It would be
difficult to comprehend why an acute engorgement of the tonsils,  for
which Flajani ventured to have recourse  to it, should ever require it,
unless it were impossible to open into the mouth and to penetrate
down to the pharynx.  The same  may be said with  greater reason
of their chronic enlargement, which is relieved by excision with much
less danger.   When the tongue becomes  swollen suddenly, in such
manner as to fill  up the mouth and close the arches of  the palate,
Richter and B.  Bell, who  recommend  bronchotomy,  had without
doubt forgotten that in  such  cases two or three deep incisions upon
the dorsum of  the diseased organ will effect its diminution, and very
probably were unaware of the observations of De La Malle on this
subject.  It would  be difficult also for me to believe that  it might
4 
BRONCHOTOMY.
137
not have been  possible  to  dispense with it  in the case where M.
Burgess performed it, since in that case there was nothing but an in-
flammatory intumescence, produced by a burn at the bottom  of the
buccal cavity.   On the other hand it is almost  universally admitted
since the time of Desault, that it is not applicable to cases of submer
sion, and that Detharding, in prescribing  it as a remedy in asphyxia
from  drowning, entirely misconceived the manner  in  which death
takes place under such circumstances.  Nevertheless, M. S. Cooper,
who considers it more prompt and easy than the introduction  of  a
gum-elastic catheter through the  nose or mouth, justly argues, as it
appears to me, that it should not then be  proscribed without  restric-
tions.   Should the mouth be firmly closed, and it became impossible
for the  catheter to be inserted into the entrance of the larynx, bron-
chotomy would be better than nothing when it was important to act
speedily and to force the air to pass into the lungs. When we reflect
upon the difficulty of shutting up the glottis completely, by means of
the tube which we insert into it, and of preventing the air, which is
blown in, from escaping into the digestive passages, in all those cases
in which the surgeon deems  it proper to attempt artificial respiration,
we cannot but be induced to accord to it a  preference  over  simple
catheterism.
   B.  QZdematous Angina, that is to say, a  serous engorgement of
the lips of the glottis, is still another disease for which bronchotomy
appears to constitute the remedy  par excellence.  In sustaining  the
respiration, it gives the physician  time to attack the disease by suit-
able remedies, and to the organism the means of subduing it, or at
least of making farther resistance to it.   The antagonists  of  Bayle,
who was the first who mentioned it for such cases, reject it under  a
pretext  which does not appear to me valid.  Their permanent canula
by the natural passages could not  certainly remain without danger in
the trachea  during  the space of from eight to fifteen days; while a
canula which has been once inserted through the artificial opening into
the respiratory tube, occasions very little inconvenience to the patient.
I am of opinion, therefore, with M. Lawrence, that in this description
of disease, which moreover is  almost  constantly fatal, it deserves
some attention, and that  it would  offer infinitely better chances of
success  than scarifications  of the infiltrated  parts, as  proposed by
some practitioners.
   The patient whom M. Roulois, of Mayenne, mentions in his thesis,
and who was operated upon at the Hospital  of St. Antoine in 1828,
by M. Kapeler, died it is true  at  the expiration of  thirty-six hours,
but after having been restored as  it were  by a miracle from death to
life, and  dying very probably because the air could not be made to pass
in sufficiently large quantity  and uninterruptedly into the lungs. The
case mentioned in the Journal Complimentaire was less  unfortunate,
inasmuch as he survived.  A woman operated upon by M. Purdon,
(Arch. Gen. de Med., 2e ser., t. II., p.  102,) also recovered.   M. C.
Broussais, (Coqueret, These,  No. 185, Paris,  1834,) was no less  for-
tunate.   Operating  for a thickening of the mucous membrane of
the larynx, M. Regnoli, (Revue Mid., 1829, t. II., p. 520,) succeeded
in two instances, and M. Senn once.  M. Fournet has published  two
other successful cases.  M. A. Robert has also communicated  to me
   vol. m.                       18 
138
NEW ELEMENTS OF OPERATIVE SURGERY.
two others which belong to him.  1 have performed tracheotomy but
twice as a remedy in cedematous  angina, and  both  patients were
cured.  We should be wrong then not  to have recourse to it under
such circumstances.
  C.  Tumors and engorgements in the vicinity.—A polypus, or any
tumor whatever in the nasal fossae or pharynx, the thyroid body, or
certain lymphatic ganglions, any of which  have become swollen or
so hard and voluminous  as to prevent the air from passing  into the
trachea, do not render the operation indispensable, only so far as there
may be imminent peril of suffocation, or if it shall have been found im-
possible or attended with too much danger to attempt the ablation of
these  morbid masses.  It was, chiefly, for these cases only that Sharp
reserved it; for it did not  appear  to him to be  absolutely  required
in the extraction of foreign bodies.  It might, moreover, be advan-
tageously performed  if,  in  consequence of a wound or otherwise,
the larynx had become completely obliterated, as in  the young man
whose history  has been given by  M.  Reynaud, (Journ. Hebdom.
Univers., t. III., p. 201.)  M. Porter, (Gaz. Med., 1838, p. 392,) em-
ployed it with  success in a case  of gangrene of the epiglottis and
hyoid region caused by suicide.  M. Warren, who undertook to per-
form it in a patient in order to  remedy the entrance of air  into the
veins; and M. Sampson, (Ibid., 1837, p. 667,) who found nothing so
advantageous to restore  a drunken man, might both, however, in my
opinion,  have dispensed with it.
  D.  Foreign  Bodies.—It is for the purpose of reaching heterogene-
ous substances which sometimes become introduced  into the larynx
or trachea, that the operation of  bronchotomy, since  the time of F.
Monavius, has  been most frequently performed.  It  has  been made
use of and might be employed in this manner, in order  to extract clots
of blood that have come from the moutn, or even from a wound in
the  larynx, lumbrici worms, a  leech (Lacretelle), flies,  portions  of
food, (Thierry,  Bibl.  Med., 1829, t. II., p. 450,)  such as  small fish
bones, (Willaume, Bull,  de  Fir., t. XXIV.,  p. 167,) fowl, pieces  of
mushrooms, apples, chesnuts, acorns, of polypus in the pharynx, a
cherry pit, a prune,  apricot, harrico bean,  raisin-seed, melon-seed,
(Jameson, Bull, de Fer., 1.1.,) a pill, a filbert, a coin of gold,  piece of
silver, locks of wool or tow, a ball, a marble of the diameter of 8 lines
(Arch. Gen. de Med., 2e  ser., t. II., p. 125,) a button mould, a pebble,
pin, needle, (Blandin, Bibl. Mid., 1829, t. II., p. 450,)  fibrous tumors,
probably syphilitic (Arch. Gen. de Mid., t. V., p. 564,) polypi (Swin-
 fer, Morgagni,  Lieutaud, Herbiniaux, Desault, Voigtel, Windt, Otto,
 rinz, Albers, R. Gerardin, &c.,)  and hydatids (Aubertin, Delonnes,
and Harless;)  encysted  tumors  (Albert,) fungous or sarcomatous
tumors  (Tortual,)  lymphatic and'  warty tumors (Wurtzer,) schir-
rhous and cartilaginous tumors  (Macllvaine in Urner, 1833, Obs.
Mid., 1835, p. 116), developed in the interior of the larynx ; a piece
of cartilage, tendon, wood,  iron, or membranous concretion; in a
word, for the  extraction  of  all  bodies whatever,  that  may be-
come  lodged in the glottis or trachea.   As soon  as the  presence  of
one of these objects in the respiratory passages is clearly established
we are justified, unless we can  reach it  better through the mouth by
means of the fingers or forceps, in calling to  our aid the resources of 
BRONCHOTOMY.
139
bronchotomy.  The sound of a small  stone  moving up and down,
and which M. MacNamara mentions, (Dub. Hosp. Reports, vol. V.,
p. 592,) after having performed bronchotomy successfully in such
cases in two instances, is a very good sign.  In the case published by
M. D'Arcy, the bean,  though the accident had happened only a few
hours before, had become swollen to treble its  size.   Though the
first  symptoms which  these substances have produced may partially
subside, it nevertheless will continue  to be  clearly indicated.  In
fact  the  monk who is mentioned in the Eph. des  Cur. de la Nat.,
and who was afraid at first to complain, died of phthisis, but not until
after the expiration of two years.
   One of the patients mentioned by Louis appeared so well that he
was  considered almost as cured, when he died near the expiration of
the third week.  Another, who lived several years with  a Louis d'or
in the bronchi, nevertheless ultimately died.  Tulpius. V. D. Wiel,
Bartholin, Pelletan and Dupuytren have  also seen in certain cases
the foreign body admit the respiration to reacquire, in some sort, its
natural function, and not cause death until after one or more months,
or even years.   There are cases also in which, after the lapse of this
space of time, the bodies have been expelled spontaneously ; as for
example,  the  chicken-bone mentioned by  Sue.   A lead  pencil, an
inch and  a half long, was thus ejected after the  lapse of six years,
(Gridley, Journ. des Prog., t. XIII., p. 269.)  M. Guastamahia (Gaz.
Med., 1838, p. 797,) mentions the case of a cherry-nut which was
thrown out in a paroxysm of coughing, after having  remained two
months  and a half in  the  trachea.   Monteggia mentions a similar
case  of a tooth swallowed by a young lady.  But these fortunate
efforts of the  system so rarely take place, that it would be imprudent
to count upon them, or ever  to dispense  with bronchotomy under
such idle pretexts.
  E. Foreign bodies lodged in the assophagus, and the inflammatory
engorgement which wounds and injuries of the neck sometimes  pro-
duce, have also induced some physicians to resort to bronchotomy in
order to prevent suffocation and give time to attack the principal dis
ease.   Habicot performed it upon the spot upon a boy who, return-
ing from the  fair,  found no better means of  escaping from robbers
than  to swallow, inclosed in a packet, the pieces of gold which he
had in his possession.   He performed it in the same manner success-
fully in a  patient who being severely wounded, was upon the point
of perishing from inability to respire.   This is the way in which we
undoubtedly ought  to  act, should life  be seriously menaced  by the
presence of foreign bodies in the oesophagus,  or by an intumescence
in the lips of a wound in the  larynx, provided it should  be impracti-
cable to remove by any other mode and instantaneously the cause
of the suffocation.  A  student of medicine, from suffering pain in the
pharynx, supposed that he had swallowed a bone  while  eating soup.
According  to  his account, this bone consisted only of a very small
fragment.   The exploration of the throat led to no discovery.   The
accidents  which were at  first quite serious, subsided by degrees;
but about the twentieth day this young man was seized with suffoca-
tion,  and vomited and threw  up a corroded bone of the size of a nut.
Bronchotomy, which nevertheless became necessary, was performed 
140
NEW ELEMENTS  OF OPERATIVE  SURGERY.
by M. Sanson,  and the general  health of M. F. was gradually re-
established.
  F.  Croup, or laryngeal and tracheal diphtheritis, that formidable
malady, the nature of which has been no less clearly elucidated than
its treatment by the admirable researches of M. Bretonneau, is one
of those  affections in which it would at first sight appear that bron-
chotomy might  be resorted to with the greatest degree of advantage.
Nevertheless, in spite of the  assertions of M. A. Severin and Bartho-
lin, and of some other practitioners of the seventeenth and eighteenth
centuries, who  assert that they had in many instances had recourse
to it with successful results, the physicians of our epochs still doubted
in 1825, if in a disease of this description it can be of any  great value,
or that there existed in science a single  conclusive or well authenti-
cated example  of cure  which could in reality be attributed to it.
Those which are cited by M. S. Cooper, whether in his own name or
in that of M. Lawrence, or of M. Chevallier, do not prove in fact that
the cases treated  by.these  physicians was legitimate croup.   The
case related in the name of Andree by Bursieri, Locatelli, Michaelis
and White, is  the only one  which is accompanied with details suffi-
ciently circumstantial to afford any satisfaction upon this point.   The
light in which bronchotomy has hitherto been considered would not
enable us to derive any very great advantage from it in croup.   We
cannot, in fact,  understand how it could  remedy the inflammation or
spasm of the larynx, which, according to Royer-Collard, &c,  ulti-
mately cause death in this disease; or the pulmonary engorgement,
any more than  it  can  the reproduction  of  the morbid product.  In
this point of view M. Caron has certainly exaggerated its  importance,
while MM. Desruelles,  Bland, &c, have very properly contested its
utility.  But it  is not in this way that it should be considered.  Pa-
tients attacked  with croup die from want of the ability to respire.
This asphyxia, which is caused by a false membrane or the engorge-
ment  of  the laryngeal membrane, does not depend on spasmodic
lesions, which are rendered impossible or insignificant in the larger
bronchi,  the trachea and the larynx, by their cartilaginous texture.
It is less with a view of extracting the membraniform  concretions
that we have recourse  to bronchotomy in this disease, than for gain-
ing time  and placing the patient in a condition to breathe while we
are devising the means for his cure.
  M.  Bretonneau has shown that when the  trachea is once opened,
we may  introduce into  it advantageously a solution of  calomel, or
even one of nitrate of silver,  and follow up the false membrane as far
as into the bronchi.   Under this point of view, bronchotomy is a  pre-
cious resource, which should be  made use of wherever  the disease,
having reached into the larynx or below  it, can no longer  be attacked
through the mouth by means of topical applications, and  where,  not-
withstanding it  has not yet passed beyond the first bronchial  divisions.
Unhoped for  successes have come to the support of this  doctrine.
In the month of July, 1825, M. Bretonneau,  being called to see Mile.
de Puysegur, four years of age, whose  three brothers had already
 f)erished  from croup, and who herself was laboring under it to a vio-
 ent  degree, freely laid open the trachea; placed a canula  in the
wound ; saw the false membranes escaping from it in great quantity 
BRONCHOTOMY.                     141
during the space of several days ; blew in calomel in powder, which
was badly  supported, subsequently the same substance diluted in
water, and thus succeeded in saving this afflicted child.  In a boy 7
to 8 years of age, and whom I had an opportunity of examining at
Tours, in 1827, a month after his cure, and who in the most advan-
ced stage of the disease had been abandoned as upon  the point of ex-
piring by his parents, M. Bretonneau laid open the trachea as in the
preceding case; saw life  returning  at the expiration of a few min-
utes ; effected the extraction  of  numerous membraniforrri concre-
tions ; and found  himself under the necessity a short  time after of in-
troducing through the  canula which he kept permanently in the
wound, a solution  of nitrate of silver as far down as into the bronchi
when, after various obstacles which were destroyed  as soon as they
made their appearance, the child was entirely restored.   In October,
1831, the same practitioner was no  less  fortunate in a third patient.
The child, which was 11 years of age, was considered as dead, when
M. Bretonneau was sent for to him.  He instantly opened the trachea,
and after various accidents which were overcome by the most  judi-
cious treatment, this young patient was  finally completely restored.
Similar successes  have been since obtained by  M. Scoutetten (Coque-
ret, These, No. 185, Paris, 1834,) M. Gendron  (Journ. de Conn. Med.
Chir., t. I. et. II.,) of Chateau  du Loir, and by M. Gendron (Acad.
Roy. de Med.. 1838, t. III., p.  391,)  of Vendome, M. Gerdy, (Chres-
tien, Arch. Gen. de Med., 2nd  ser., t. V., p. 517,)  M. Crozat (Precis
Med. d'Indre et Loire, 1833, p. 5,) and especially by M. Trousseau,
(Journ. des Conn. Med. Chir., t.1. II.,  and III.)   Out of 18 or 20
operations, M. Bretonneau at the present day counts five or six cures.
Out of 60 cases and over, M. Trousseau points out more than 20 suc-
cessful results.  I  must  however  remark,  that I lost  the four  chil-
dren upon whom I performed  it, and that  up  to the present time, it
has been unavailingly made trial of  in a great number of patients at
the Hospital des Enfans.   It has been decided upon too late, as has
been remarked by M. Maingault,  (Arch. Gen. de Med., t. XXX., p.
419; 2nd  ser., t. I., p. 129,) and the  consecutive treatment  requires
too many precautions to allow of its succeeding with every one as
well as it  did with MM. Bretonneau and Trousseau.
  G. There are also other  diseases which it would  appear to me
might  be advantageously treated  by  bronchotomy.   Laryngeal
phthisis, for example, and chronic phlegmasias, which ultimately re-
sult in producing a degree of contraction in the glottis, as in the case
cited by M. Gintrac, (Revue Med., 1830, t. I.,  p. 106.)   The air find-
ing a free  passage  below the disease, would leave the larynx in re-
pose, and would no longer interfere  with the  salutary efforts of the
system.   Moreover, we should  thus be enabled to place through the
new opening, should it become necessary, topical applications imme-
diately in contact with the diseased part.  Trials of this kind have been
made since  being  recommended  by me; a pregnant woman affect-
ed with a  syphylitic ulcer  in the larynx, and upon the point of suffo-
cating, was cured in this manner by M. Purdon, (Arch. Gin. de Med.,
2nd ser., t. II., p. 102.)  A man who had ulcers of the same charac-
ter, accompanied with engorgement of the cordae vocales, and whom
I  operated upon at the Hospital of La Charite, in the month of No- 
142
NEW ELEMENTS OF OPERATIVE  SURGERY.
verdber, 1838, was  also restored.  M. Trousseau and M. Amussat,
by  operating in this manner in cases of tubercular phthisis, have
prolonged at least the lives of some of their patients.
  H.  Horses affected with cornage also have the glottis contracted,
and present to  the observer experiments, all of  which are  at  hand,
in favor of what I have just advanced.   Two of these animals em-
ployed in a manufactory of minium at Tours, recovered their ordi-
nary condition  of health after having  had  a large  canula fastened
into their trachea.   M. Barthelemy (Bull, de la Fac.  de Med., t. VII.,
p. 27,)  and other veterinary practitioners, have cited cases  that are
nearly  similar.  Applied toman, these  facts have not deceived  the
expectation of practitioners.  M. Clouet,  of  Verdun, (Journ.  de
Prog.,  t.  XVII., p. 226,) caused a similar canula to be worn for the
space of twelve years, by a woman  whom a  fistula  in the larynx,
and other wounds, had exposed to  the risk of suffocation.  Price im-
puted ten  years of flourishing health  to a remedy of this description.
M.  Bulliard, in 1824, restored  to  health a young soldier  whom a
chronic laryngitis, and not  croup as he supposes, had  brought to the
verge of  death  after many paroxysms of suffocation, by placing in
his larynx  a canula, which the patient  wore during  fifteen  months.
M. Godeve was no  less fortunate, in 1825, in another patient, affect-
ed, he says, with an ulcer in the  larynx, but rather, as I think, with
an engorgement of the cordae vocales, and who was enabled to re-
move his  canula without any inconvenience at the expiration of six
months.   The patient  of M. White  carried it for the space of two
years,  and that of  M. Senn eleven months.  The  same occurred
nearly  in the two patients operated upon by M. Regnoli.
  I.  Recapitulation.—In conclusion, bronchotomy  is an  operation
to be made trial of in all  cases, or nearly in all  cases, where a me-
chanical  obstruction from whatever  source it may arise, has a ten-
dency to produce asphyxia.  M. Gendron, (Journ.  Hebdom., 1836,1.1.,
p. 380,) who has seen two  cases, proposes even  that should  a fistula
exist between the  trachea and oesophagus, bronchotomy should be
had recourse to in order  to cauterize the fistula through his bivalve
canula.  The operation,  in  reality, has but little danger connected
with it.  If up  to the present time it has  not been more frequently
performed, it is from its effects, except in  cases of foreign bodies, not
having been accurately understood;  from its having been supposed,
that in order to re-establish respiration it  was sufficient to open any
passage whatever for the  air;  and from not having reflected that
if the artificial  opening is perceptibly less in extent  than the natural
passages, the lungs  remain incapable of completely  performing their
functions, and that, in such cases, the design of the operation is to a
great extent defeated.  This is a truth  which, placed beyond all dis-
pute by M. Bretonneau, I consider that I have established,  and  the
practical  consequences of  which ought to be of  the  most beneficial
character.   In one of the horses just mentioned  the  tracheal canula
was only six  lines in diameter.  As  soon as the  animal  became
fatigued, he was seen gasping and out  of breath.   A large canula an
inch in diameter was  substituted for the  first, and the horse imme-
diately breathed freely and could undergo the  most  violent exercise.
In the  little patients who were cured  by the practitioner of Tours by 
BRONCHOTOMY.
143
means of bronchotomy, was not the canula naturally too small, or
made so by the concretions and  mucosities which contracted its di-
ameter ?   Though the symptoms  of  asphyxia momentarily  disap-
peared, they were found speedily to return.  But on the contrary,
it was no  sooner  cleared out, or a larger canula made use of, than
the child seemed to revive.  The same effects were  observed in the
cases of MM. Bulliard, Senn  and Trousseau, and I was  enabled to
demonstrate, on my part, to a great number of persons, the correctness
of this observation in regard to the patients whom I operated upon
at the Hospital of  La Charite in 1837 and 1838.  W. Cullen, (Journ.
de Prog., t. VII., p. 144,) who neglects to give credit for this sugges-
tion to M. Bretonneau. collected, in 1827, other facts not less conclu-
sive, in order  to sustain it and to  give currency to  it in England.
After all, every  one may, on this point,  experiment on  himself.
Should we, for example, diminish  the volume  of the column of at-
mospheric  air which is naturally inspired into the lungs, or diminish
the openings  of the  nostrils one-half or two-thirds of their  dimen-
sions, by closing  them upon  a portion of  quill  or  gum-elastic ca-
theter, and keeping the mouth shut; the respiration will  not  be ar-
rested, but it will soon become painful, and so much the more so in
proportion as the passage for the air shall be more contracted   It is
important then, when we  venture  to have recourse to bronchotomy,
with the view of sustaining an artificial respiration beyond the space
of a few minutes, that we should open largely into  the respiratory
tube, and that we should  leave  in the wound a canula also of very
large diameter.

              § II.—Examination of the  Methods.

  This leads us to examine which ought  to have  the preference,
tracheotomy, laryngotomy, or laryngo-tracheotomy.  The ancients
had no occasion to discuss this question, as they attempted only the
opening of the trachea.   The  opening into the  crico-thyroid mem-
brane, has  only been  employed in practice since the time of Vicq-
dAzyr, who proposed it  before  the close of the last century.   De-
sault is the first person who suggested the  division moreover of the
thyroid cartilage upon the median line, and it is to  Boyer to whom
we are indebted for the idea of incising at the same time from above
downwards, the cricoid cartilage and the first rings of the trachea.
  A.  Laryngotomy, after  the manner  of Vicq-d'Azyr, and adopted
by a great number of surgeons, possesses the advantage of being the
most easy method, of acting upon  a membrane which is but slightly
organized  and superficially situated,  of not incurring the risk of
wounding  any vessel or any important organ,  and of leaving the
glottis intact;  but on the  one hand, it  does not procure an opening
sufficiently large  to  admit of the introduction  of  instruments re-
quired for the extraction  of foreign  bodies, while on  the other
hand, the canula which it would allow us to employ would be  rarely
large enough to admit of a sufficient quantity of air.  In imitating
Desault on the contrary, as has been done  in America and in Eng-
land, and  as is also  practised  by M. Whithley and  M. Blandin, we
open into the larynx  as freely as possible,  and no vein or artery of 
144
NEW ELEMENTS OF OPERATIVE  SURGERY.
 any size runs any  risk of beino- divided.  It is the only means in
 some sort of laying bare the foreign bodies, which in most cases be-
 come  imbedded or arrested between  the  lips of the  glottis, or the
 polypi or other vegetations, which also are rarely seen except in the
 vicinity of this part.   Nevertheless, though the lesion of the cordae
 vocales, which has been  so much dreaded  by those who have op-
 posed  Desault, may be easily avoided, and is moreover a matter of
 little consequence, and though the voice in patients treated by this me-
 thod may not have  suffered more injury than by any other, it does not
 however merit the  preference, except in  the cases  which have just
 been  pointed  out;  moreover, the patient should not have  reached
 that time of life, when the thyroid cartilage has become  charged to
 too great  a degree with phosphate of lime.   Should the dread  of
 wounding the cordae vocales deter him, the surgeon would  have to
 do nothing more than to adopt  the advice of M. Fouilhoux, and in
 order to avoid them, divide the  thyroid cartilage  upon its  side, and
 then lay open the soft parts of  the glottis transversely.   When the
 foreign body is situated below the larynx, or that it becomes advisa-
 ble to insert a tube  into the wound, it is evident  that this process
 can no longer be applicable.  Perhaps rigorously speaking, it might
 even be  possible to  replace it  always by another oparation which
 has been proposed by M. Vidal (de Cassis)  with the view of opening
 abscesses  of the glottis, and  also  by M.  Malgaigne ; an operation,
 the first suggestion  of which  no doubt was derived from the experi-
 ments of Bichat  upon the. voice, and  which consists in penetrating
 into the larynx through the  thyroid  membrane.   Nevertheless  an
 operation of this kind has something in it repugnant, at least at first
 view, which admonishes me to dwell no  longer upon it,  notwith-
 standing it  succeeded  very well in the trials which I have made with
 it  upon the dead body.
   B.  Laryngo-tracheotomy,  which  ordinarily leaves  the  thyroid
 gland entire, and which incurs  the risk of wounding only the crico-
 thyroid artery, does not enable us, like the method of Desault, to ex-
 amine  into the bottom -of  the larynx ; being too remote from the
 bronchi for foreign bodies, possessing but little mobility, to reach
 with facility the  opening which  has been made, the division at the
 same time  is in  too near proximity to the glottis, not to render the
 employment of a permanent canula dangerous; so that in spite of its
 inconveniences, tracheotomy still appears to combine the most advan-
 tages under all circumstances where the method  of Desault is not
 absolutely required.
   C. Tracheotomy.—The trachea, which is a sort of cylindrical canal
 which  descends  to  a  line with the second or third dorsal vertebra,
 and composed of about twenty cartilaginous rings and resting against
the oesophagus rather more on  the  right side than on the  left, is
covered: 1st, by the common integuments ; 2d, by the cervical apo-
neurosis ; and 3d, by the uniting  bridle of the thyroid lobes close  to
the cricoid cartilage ; lower down by the supra-sternal venous plexus,
and the middle thyroid artery when that exists ; 4th, slightly upon its
side by the sterno-hyoid and sterno-thyroid muscles.  Accompanied
 posteriorly  by the inferior laryngeal nerve, and at a considerable dis-
tance from  it by the primitive carotids, it is sometimes crossed by one 
BRONCHOTOMY.
145
of the thyroid arteries, which in that case goes from one side of the
neck to the other.   In infants especially, the trunk of the innominata
almost always conceals its anterior surface, even as high up as above
the thorax;  so that the right carotid also does not leave it until at a
point  very high up, where it takes a situation completely on one side
of it.   I have also seen  the left carotid originate upon the right side
and pass in front of the trachea, in order to reach its usual destina-
tion, and that of the right side do the same.  Other vascular anomalies
also have been  met with in this region, and deserve no less attention
than  the preceding.  From all these relations it results that  the
trachea, which is  sufficiently  superficial above, where  the  thyroid
gland, which protects moreover its lateral portions, alone almost sepa-
rates  it  from the integuments, becomes deeper and deeper in  propor-
tion as it descends  or inclines towards the chest in order to follow the
thoracic concavity of the spine, and that at the lower  part  of  the
neck we are obliged to seek for it more than an inch deep under the
integuments.  Finally, from the great mobility it possesses we might
very  readily, when  seeking to lay it  open, if we were not  on  our
guard, push it so much  aside that the instrument might fall upon the
primitive carotid, as happened in a case  mentioned by Desault, and
where it is seen that a pupil of medicine, who was in a state of
asphyxia, was killed in  this manner by one of his companions who
was endeavoring to save his life.
   I. The ancient authors, who recommended bronchotomy, restricted
themselves  probably like Antylus, to dividing transversely  at  the
middle of the neck the integuments  and space between the third and
fourth rings of the  trachea.  J. Fabricius  is the first person who pro-
posed to perform the operation in two stages : first, to incite  the  soft
parts  from above downwards upon the median line, and then to open
into the respiratory duct in  the manner performed by the ancients.
He recommends moreover  that we should leave in the wound a
small  straight canula furnished with wings; a canula which Casseriusi
caused to be slightly curved, which, according to C. Solingen, should
be flattened, the external opening of which Moreau covei ed with a
small  portion  of lint, and  Garengeot with  a piece of muslin, in
order to intercept  foreign bodies.  In order to prevent its obstruc-
tion and not to be  compelled to withdraw it when we wish to clean
it, G.  Martine  found an advantage  in  inserting two, one within  the
other.   Ficker, who adopts the idea  of  Martine, requires that  the
outer one should be made of silver and the inner of gum-elastic, and
that both should possess a certain degree of curvature ; finally, some
moderns have  maintained  with Ferrein that it could be advanta-
geously replaced by a portion of quill.  The manner of inserting and
fastening this canula has varied no less  than its  form.   Sanctorius
adjusted it by means of  a trochar, and Dekkers inserted it into  the
trachea by dividing also the skin with the same instrument.  Moreau
made a passage for it between  two rings by means of a simple lancet,
and Dionis  suggested that it  should be conducted into the tracheal
tube upon a probe.   That of Bauchot  is very short and flat, and its
inventor, who moreover made use of a kind of crescent mounted upon
a handle in order to steady the larynx, had, like Dekkers and Sanc-
torius, a stilette of  the same form, with a cutting edge at its extrem-
  vol. hi.                      19 
 146           NEW ELEMENTS OF  OPERATIVE SURGERY.

 ity, that it might traverse the skin and penetrate, by the same move-
 ment, into the trachea.  Richter (Biblioth. Chir. du  Nord, p.  234)
 incurvates the instrument of Bauchot into an arc, with the view of
 rendering it more supportable, and maintains, as M. Collineau (Arch.
 Gen. de Med., 2d ser., t. I., p. 589) has done  since, that by means of
 the puncture from the wound of the trachea being immediately filled
 up by the canula, the hemorrhage becomes  infinitely more  difficult
 than by incision of  the tissues.   But this  is  an error, and whatever
 Bergier and B. Bell may have said of it, all these modes of arriving
 by a single operation into the canal, are at the present day generally
 and properly proscribed.  The fear of wounding the cartilages  also,
 again revived by Purmann, no longer attracts the  notice of any
 one.  Heister  has clearly demonstrated  that we may divide them
 without the slightest risk.   Vigili of Cadiz who was obliged to divide
 them as far down as to the sixth ring in a soldier, in order to prevent
 the danger of suffocation which the ordinary incision  had produced
 by causing an effusion of blood into the trachea, and who, in place
 of a canula, kept in the wound a piece of  sheet lead curved upon its
 borders and perforated with  holes, found no reason to  regret  it.
 Wendt, with the view of extracting the half of an acorn, ventured to
incise three of these cartilages, and Percy on  this subject advises that
 we should use the scissors instead of the bistoury, which latter how-
ever is much more  convenient, and preferred with good  reason by
almost every practitioner.
  II.  It is doubtless already anticipated what are my views upon the
importance  of these numerous modifications of  processes.   In the
 first place, I would recommend the rejection of every  kind of trans-
verse incision.  If the obstruction  to be removed is a  foreign body,
the division of one  of the intercartilaginous spaces will  not prove
sufficient,  and if the object of the operation is  to enable the patient to
breathe, a wound of this description will never be found sufficiently
large.  If any other proof were found wanting, it would be found in a
case operated upon in my presence in one of the large hospitals.  The
opening of the trachea had been well made and the canula properly
 adjusted, but it was a portion of gum-elastic catheter, and the patient
 compelled to breathe through so small a  tube  found himself partially
 relieved only of  the suffocation, which it had been attempted to re-
 move by means  of  the bronchotomy.  In the first case the  canulas
 and perforated plates  are useless.  As soon  as the trachea is  free
 we must reunite the wound  or let it close up.  If the foreign body
 is movable, the air  of the lungs may expel it outwards.  If it does
 not present itself spontaneously at the wound, we must proceed  to
 search for it in the direction of the bronchi, by means  of a  pair of
 curved and delicate forceps or some other appropriate instrument.
 When it becomes impossible to reach it or meet with it, it must be
 abandoned, and  the wound  left open and the patient  dressed.   On
 the following day or the day after, it is generally found on the deep-
 seated surface of the dressing.  Desault, Pelletan and Dupuytren have
 in this manner noticed  the expulsion of a bean, kernel  of fruit, piece
 of money, &c, and the needle that M. Blandin was unable to seize, after
 having divided the thyroid cartilage, also made its exit in the same way.
 In the second case the canula is  indispensable, but as no author had 
BRONCHOTOMY.
147
pointed out the importance of a large and permanent opening in the
trachea, none of the tubes that have  been proposed answer the pur-
pose.  That of M. Bulliard is cylindrical, long and strongly curved.
M. Bretonneau has caused several successively to be constructed of
various kinds.   The canula which he used in Mile. Puysegur is dou-
ble  like that of Martine, and flattened, slightly concave jpn  its  in-
ferior  border, and  four lines in breadth in  its  greatest diameter.
That which he used  in the patient whom I  saw, is formed of two
halves, one  superior and the other inferior, which are  placed sepa-
rately  in  the  wound, and  which when once reunited, present  no
other than an instrument analogous to the preceding.  M. Scoutetten,
(Coqueret, These, No. 185, Paris, 1834,) M. Lawrence, (Ibid., p. 21,)
M.  Trousseau, M. Coqueret, (These, No. 185, Paris, 1834,) M. Mo-
reau, (Gaz. Med. de Paris, 1838,) Boyer, (Coqueret, Thise citie, p. 24,)
M. Sanson, &c, have since contrived others; so that at the present day
we possess those that are simple, double, flattened, cylindrical, eyed,
crib bled, and bent into an angle or curved into an arc.   In ordinary
cases that of M. Bulliard is most convenient; under other circumstan-
ces we should have recourse to  M. Gendron's, (see the Atlas ;) the
important point is, that it should be sufficiently large and frequently
cleansed.
  III.  Whether we do or do not wish to make use of a canula, some
persons have  proposed that we  should  not  restrict ourselves to a
simple section of the cartilages  of the trachea, but remove and ex-
cise a  flap  of the anterior wall of this canal.   It  appears that ve-
terinary surgeons very frequently proceed in this manner.  Andree
also appears to  have followed this process,  which is  formally re-
commended by M.  Lawrence, M. Porter, (Dublin Hosp. Rep., vol.
V.,  p.  560,) &c.  But it is  a precaution which is at the same time
wholly useless as well  as dangerous: useless, because the pure  and
simple  incision always enables us to  introduce  the artificial tube;
dangerous, because  if it should become afterwards advisable to  let
the wound close up, there would necessarily result from it an incura-
ble contraction of the respiratory passage.  Consequently the process
of M.  Collineau, (These, No. 676, Paris, 1829,)  to accomplish  this
loss  of substance, and  at the same time to  render every  kind  of
hemorrhage impossible; a process which consists in perforating the
trachea by means of a cutting-plate, making  a projection upon the
circumference of a flattened disc of copper heated to  a white heat,
and which is mounted upon a long handle, in  my opinion appears to
possess no utility, and ought to  be abandoned, as well  as the advice
of MM. Carmichael and White, which has the same object  in view.

                   § III.—Operative Process'.

  A. The instruments  for bronchotomy are composed  of a straight
or convex bistoury ; a blunt-pointed bistoury ; several canulas armed
with threads, and everything which may be required to  attach them ;
very delicate ring and polypus forceps ; several simple ligatures and
some needles ; erignes or sounds curved in the form of hooks, and
various articles of dressing.   The patient being placed upon his back,
should  have the head  only slightly reversed. Verduc has shown 
148
NEW ELEMENTS OF OPERATIVE SURGERY.
that by inclining it too much  backwards the respiration is rendered
more  difficult, a  remark which is applicable, moreover, to all the
modifications of bronchotomy.   The  surgeon being placed on the
right, in order to incise from above downwards, and not from below
upwards, as some persons recommend, grasps and steadies the larynx
with  his left hand, while with a convex  or straight bistoury  in his
right hand he divides the tissues.
  I.  Tracheotomy.—In  order that tracheotomy may  be  well per-
formed, it is necessary that the  wound of the  soft parts  should ex-
tend from the neighborhood  of the  cricoid cartilage  as  far  down
nearly as the sternum.  After the integuments and aponeurosis we
come to the vessels which are to be tied  in proportion as they are
divided; the veins of the thyroid plexus,  which should also be tied
when it appears  impossible to avoid  them; then the middle  thyroid
artery, when it exists, and which it would be dangerous  to wound.
When arrived upon the front of the trachea, should the  blood flow in
abundance  and no necessity exist for haste, we  may rest for  some
minutes in order that the respiration may arrest the hemorrhage ; but
if it is necessary to be rapid we hasten to pass threads around the
vascular branches which bleed; or,  what is still better, we imme-
diately proceed to lay open the  respiratory tube itself.   Though the
straight bistoury, held as a pen, is sufficient for  effecting this opening,
which ought to  comprise at  least the fourth, fifth, and sixth,  if not
the  third and seventh cartilaginous rings, there are, however, practi-
tioners who prefer the blunt-pointed  bistoury to extend the  incision
after the puncture.  I see neither any inconvenience or advantage in
this :  though even the point of the instrument should touch the poste-
rior wall of the respiratory tube, which seems to be so much dreaded,
there  would probably result from it no very serious danger.  This part
of the operation being terminated, we proceed differently, according
as we have to extract a foreign body or to relieve the suffocation.
In the first  case, should the body which is  to be removed not be ex-
pelled instantly, then if it presents itself at  the wound, whose lips the
operator is  to cautiously separate apart by means of the ring forceps
or hooks, we endeavor to reach it with a suitable instrument, and to
draw it out.  When it remains immovable in  the direction towards
the  bronchi, which, as Favier has shown, is quite rare, we insert, with
every precaution possible, in  this direction a  suitable  forceps  or  a
small scoop, in order  to detach  or seize it.  Should such researches
prove unavailing, they should not be too often repeated.  Should the
surgeon have no other object in view than to establish artificial res-
piration, he immediately proceeds  to adjust  the  canula.   Having
seized it, he places it  in the trachea, while with the ring forceps he
separates the lips of the wound wide apart.  By conducting it upon
a probe or  canulated  sound, which serves as an axis  to it, I ordina-
rily succeed in introducing it into the wound without  any difficulty.
If during the operation the venous^hemorrhage should  be too  abun-
dant,  and resist the ordinary means, we should not get  alarmed and,
in our fright, abandon the  patient, as Ferand  did in a  similar  case.
If the patient is at the age of reason, we should soothe him  and in-
duce  him to respire as freely as  possible, when the blood soon stops
of itself.  Should any of it escape into the trachea and give rise to 
BRONCHOTOMY.
149
accidents, it would be an additional inducement to imitate Vigili, and
immediately lay open the respiratory tube largely, as I did in one in-
stance successfully in 1838.  We might also, after the manner of M.
Roux, (Lancette Franc, t. I., p. 182,) should the danger be pressing,
apply our mouth on a tube or the end of a gum-elastic catheter, in-
troduced into the wound in the trachea, in order to suck out  the ex-
travasated fluids which lead to the apprehension of suffocation.
  II.  Cricoidean Laryngotomy.—When we  wish to  lay  open the
lower part of the larynx the incision is to commence at the project-
ing angle of  the thyroid cartilage,  and  descend a little below the
cricoid, without the  necessity however of making it as long as for
tracheotomy.   The surgeon divides in  succession, or with one cut,
the skin, subcutaneous layer, and aponeurosis ; separates the thyroid
muscles;  places the  pulp of his forefinger upon the  crico-thyroid
membrane ; endeavors to feel  the artery of the same  name; raises  ;
it up or depresses it with his nail, according as he wishes to incise  it
above or below ; plunges his  straight  bistoury, guided upon the nail  j
of one of his fingers,-perpendicularly  into the membrane; turns the  ^
cutting edge of his instrument upwards or  downwards, according as  '
he has succeeded in  pushing the arterial arcade to one side, or the
other, and makes in this place an opening of the proper dimensions.
  III. Laryngo-tracheotomy.—In order to transform the preceding
operation into laryngo-tracheotomy, as M. Duchateau (These, Stras-
bourg, 1823,) has in one instance successfully done, we have nothing
more to do than to insert a blunt-pointed in place of the straight bis-
toury, and to enlarge  the wound from  above downwards by dividing
the cricoid cartilage  and first  rings of the trachea upon the  me-
dian line.
  IV.  Thyroidean Laryngotomy.—The same instrument directed
from  below upwards accurately upon  the median  line, would serve
full  as well to separate the two halves of the thyroid cartilage, after
the  manner of Desault.  Upon the supposition that in spite of every
precaution possible, the  crico-thyroid  artery has been divided, and
that it may give rise,  which is  difficult to comprehend, to an alarm-
ing hemorrhage, it could be easily surrounded with a ligature upon its
right and  left, and it surprises me that  a vessel of so little importance
has attracted so much attention.  The little finger inserted into the
wound is first made to  proceed in  search of the  foreign body, and
then serves as a director to the  forceps or  other  instruments which
it may be deemed advisable to employ.  As soon as the body is re-
moved, the wound is  to be reunited by first intention, and the cure
is generally effected  in a very short time.  When,  however, we
have not been enabled to find it, the wound is to be left open and we
proceed afterwards  in the same manner as in tracheotomy.  In my
opinion, moreover, the suture recommended  by some authors and
used by Herhold, ought  never to be made trial of, whatever Delpech
and M. Serre say of it.   The  patient  mentioned  by Wilmer, and in
whom it was  made use of, died suddenly on the  fifth  day after the
operation.  It can only have a tendency, in such cases, to favor the
extravasation of sanguineous or other fluids, either between  the air
passage and the tissues which surround it, or into the interior of this 
 150          NEW  ELEMENTS OF  OPERATIVE SURGERY.

 canal itself, while the other containing means are always sufficien*
 for reunion  in a wound  of this description.
   V.  Thyro-hyoidean Laryngotomy.—After  having laid bare  the
 thyro-hyoidean membrane upon the median line, by means of an in-
 cision about two inches long, it will be found less difficult than might
 be supposed,  to  reach the superior cordae  vocales, provided  we
 divide it transversely above the cartilage which gives attachment to
 them.   A bistoury plunged in  at  this point from above downwards
 and from before backwards, traverses the root of the epiglottis, falls
 immediately into the larynx, thus  making for the finger or forceps a
 passage, which can  be enlarged at pleasure,  and which enables us
 to pass round the whole of the glottis without wounding in any way
 whatever either the cordae vocales or the cartilages.   No artery of
 any size nor any important nerve  can be wounded.   The laryngeal
 branch of the superior thyroid artery and the corresponding nerve
 are sufficiently distant from the  median line, to enable us to avoid
 them with ease, and  no venous  plexus is encountered at this point.
 The wound made by this operation might have, I should  think, some
 tendency to remain  gaping open, but  it is probable  that in living
 man the inflammation  would  speedily approximate its borders, and
 that cicatrization would be effected without difficulty.
   B. If our  intention is to restore the respiration of the patient,  and
not to extract any foreign body from the aerial  passages, the surgeon
having satisfactorily removed the suffocation, has still to attend to two
things, to wit, the disease of the larynx and the canula which he has
left in the wound.   Under the first point of view therefore he will have
recourse to antiphlogistics, general or local, to resolvents, detergents
 and even caustics, either by the mouth, or on the skin or wound, and
 to blisters, antisyphilitics, &c, according as the disease may be laryn-
 gitis, croup,  ulcers or a venereal affection of the larynx.  As to the
 canula, it is  important  to  have at least  two of them, and that they
 should be changed or cleansed  as  often as the respiration appears to
 be incommoded.  They are to be  kept in place by means of two rib-
 bons of  some  breadth, which  are to be crossed  on the nape  and
 brought  forward  to be  attached  by a bow-knot in front of the
 neck at the supra-sternal fossa.  Patients should wear this canula as
 long as the air does not pass freely through the glottis.   There are
 some, moreover, who dispense with them without danger at the end
 of the first  or  second month, while there  are others who have to
 wear them for one or several years, and even during all their lives.

 [LARYNGOTOMY  AND TRACHEOTOMY  FOR  FOREIGN BODIES, CROUP, ETC.

  There will doubtless be  sufficient time to make improvements in the
 method and  instruments to be employed in laryngotomy, and  in tra-
 cheotomy, for  croup, &c, after the operation  itself shall have ever
 received the sanction of the profession, under any circumstances ex-
 cept for the removal of  foreign bodies. Though  the pathological
 condition of the system, which results in the production of the false
 membrane in croup, even throughout every ramification of the bron-
 chial tubes,  has no parallel with the perfectly sound state of the air
 passages, when foreign bodies have become lodged  there,  still the 
•
                         BRONCHOTOMY.                      151

restless impatience of innovation is  such, that some surgeons have
already, before the propriety of the operation in croup, at all, is yet
decided upon, begun, like Dr. Morand among others, (Recueil des Tra-
vaux de la Soc Med.  d'Indre et Loire, in Gaz. Med. de Paris, 1846,
XVI. annee,  3e ser., t. I., p. 210,) to refine upon the character of the
wound and the nature of the instruments required to perfect the pro-
cess in question.   Thus, to prevent asphyxia, and the desiccation of
the mucus of the passages, and the better to reach and draw out the
glove-like prolongations, he proposes to open into the trachea largely,
also to dispense with  the canula, and to dilate the wound by instru-
ments  for that purpose, and then to place over it a thin gauze, in
order that it may  become moistened by the air expired.   The dila-
tation of the  wound must expose to greater hemorrhage) and there-
fore to greater danger of blood  passing into  the trachea, and stran-
gulating the patient.   As to the hope of thinking to extract the false
membrane after it is once formed, it  appears, in  our judgment, alto-
gether chimerical.
  Mr. Lawrence thinks laryngotomy by a small  aperture, with the
two-edged bistoury, into the crico-thyroid membrane, quite sufficient,
and preferable to tracheotomy in all cases  where we desire to obtain
artificial respiration.  The former is unattended with danger, while
in  the latter we  may have  serious hemorrhage  from  the thyroid
veins, (London Med. Gaz., June 20, 1845.)  But the serious charac-
ter of the hemorrhage, as we have explained in our  notes, arises
from the danger of some particles of blood getting into the trachea,
and causing  immediate  convulsive  strangulation, suffocation, and
death.  This  is most  to be apprehended  in children, wherever the
opening may be made, as the vessels, especially the veins, become
enormously distended, and enlarged, and engorged, by their cries
and struggles, as in the case (vide infra,)  of the  removal of a large
dressing or shawl pin by Dr. Mott.  Mr. Coote,  in examining the
false tubular  membrane  in  a case Mr.  Lawrence operated upon,
found  it to be a yellowish  soft coating,  extending throughout the
minutest ramifications of the bronchi of the  left lung.   This adult
had been laboring  under bronchitis, (lb., loc. cit.)   Mr. Coote ascer-
tained that the membrane constantly preserved its tubular character,
that it was of the thickness of the mucous membrane, and that it con-
sisted  of pure fibrine.  Mr. W. Chapman, on the other hand, in a
ca.se of acute laryngitis, (Lond. Lancet, June 7, 1845,) made his in-
cision  longitudinal, and half an  inch long, and just one inch above
the sternum,  and then introduced the tracheotomy trochar and can-
ula.  He  insists that  this is  the best place in such affections, and
especially because we thereby save the  patient  from  the  irritation
caused by air passing over the inflamed surface  of the  larynx.  He
properly insists that it should  be  performed early, and before the last
suffocating stages  have arrived.  This, we perceive, by what takes
place in respect to the deposition of the false membrane  above, is
correct reasoning.   Mr. Chapman saved and cured his patient.  Mr.
Liston also prefers tracheotomy in  all diseases of the larynx and
glottis, and in a majority of the cases of foreign bodies in the air pas-
sages, especially if they are in the trachea, (London Lancet, Nov. 23
1844.)  His object is  to have a large opening, and also in laryngitis
                                                 • 
152
NEW ELEMENTS  OF OPERATIVE *SURGERY.
 to get below the disease.  Where  the canula has to be left in, Mr.
 Liston says the patient can generally clean the tube of mucus by
 putting the finger partially over the outer end of the tube, so as to
 narrow it, and excite resistance to  the expiration, and thus promote
 a  slight  cough, (lb.)   A double canula allows you to  clean one
 while the other is left in.
   M. Vogelvanger (Annates de la Societe de  Med. cTAnvers,  Gaz.
 Med. de Paris, and also the Provincial and Med.-Sarg. Journ., May
 27, 1846, p. 247,) succeeded, in 1840, in extracting a large slice of a
 carrot, nearly an inch and a half in length,  which had become im-
 pacted or wedged into the upper part of the larynx, in a girl between
 five and six years of age.  As the incision into the trachea afforded
 relief to the respiration, as a return of suffocating  symptoms  took
 place when the wound was  closed, and as the body could not be
 seen, the surgeon  naturally thought this latter was above the wound
 made.  Introducing, therefore, a dressing forceps upwards, the  por-
 tion of carrot was immediately  extracted, and  the patient's life thus
 saved.
   A remarkable and instructive  case in which tracheotomy was per-
 formed, is one which  occurred  in the practice of Mr. J. Elkington,
 at Birmingham, England, (Provincial Med. and Surg. Journ., April
 22, 1846, pp. 184, 185.)  The patient, a woman  aged twentv-six, in
 the ninth month of her pregnancy, was seized, January 6, 1846, with
 a  croupy cough, bloody expectoration, and loss  of voice, which in-
 creased, together with  suffocating paroxysms to such degree,  that
 the trachea was opened at the usual place, January 17,  which gave
 much  relief.  The same evening labor came on, and on the next day,
 January 18, she was delivered of a dead child without any difficulty.
 On the morning of the 19th she slept two hours.   The  breathing
 being  then worse, the canula was removed, and at half past three^
 P. M., an attempt  made to enlarge the opening, by which means a
 vein was divided and  some blood got into  the passage.   At four a
 dreadful convulsion came on, and  she expired.  The appearances
 after death presented a false membrane of coagulum  lymph on the
 entire  mucous lining of the air passages,  larynx, trachea, and bron-
 chial tubes, down to their smallest ramifications.  Here is an  une-
 quivocal and  aggravated case of croup, in which leeching and other
 depleting and antiphlogistic measures do not appear to have been
 carried sufficiently far.   This case also calls up again the subject of
 the extreme danger of the entrance  of the blood into the trachea in
 tracheotomy, (vide infra,) and the question, how far the attempt to
 enlarge the wound may  have led  to the immediate fatal result.
  A foreign body will play up and down in the trachea like a pea in
 a quill, for weeks, without other  inconvenience than  occasional  fits
 of coughing.   Finally it will become permanently lodged, probably
 in  the  rima glottidis, and may there suddenly cause death  by suffo-
 cation during an access of coughing, as in the case of a pebble swal-
lowed by a  little girl, between two and three years of age, as related
by Mr. Pitcher, (Lond. Lancet, 1844,) and also in the case of an infant
mentioned by the same  surgeon, and in whom a piece of cabbage'
stalk was found, after death,  to  have got  imbedded between  the
cordae  vocales.  Laryngotomy  would  have  saved  both,  perhaps. 
BRONCHOTCMY.
153
The same surgeon, (lb.) called to a child who had swallowed a tama-
rind stone, at once proceeded to open the trachea, but found no evi
dence with the forceps of any foreign body.  Bronchitis ensued, and
under the supposition that the operation might have caused this, the
wound was closed up. Death followed, and a tamarind stone was
found imbedded in the upper  part of the right lung, having passed
through the right bronchus.  The lung was one mass of disease, and
in quite a pulpy condition.
   A girl aged 16, at the city of Dublin Hospital, is stated by Dr
Houston, (Dublin Med. Journ.,  1844, vol.  XXV.,  p. 532, &c.,)  to
have swallowed, about a month before Feb. 1841, a fragment of wood,
while laughing with it in her mouth.  She suffered especially at night
from fits of coughing, and  had a constant mucous  rale, with stridu-
Ious croupy breathing.  The coughing however, was always reliev-
ed by a  sup of any liquid.  Tracheotomy was  performed by Dr.
Houston, May 19, which brought on a violent paroxysm of coughing,
probably from inattention to accurate sponging of the wound, and
previous careful ligature or torsion to all the  vessels, so as to pre-
vent the slightest introduction of blood  into the tube.  [See what
we have elsewhere said of the  opinion of Dr. Mott, on this point]
During a violent paroxysm, and  not until the month of August, was
the fragment thrown up, which proved to be a wooden peg  of a boy's
fiddle, after  which she  recovered rapidly, though in fact her general
health had never been impaired.   It is remarked in this and all other
cases, that the upper parts of the air tube about the glottis may  be
freely explored without causing  any  irritation, whereas it is the re-
verse in  the direction towards the bronchi.   In a child aged six years,
a small brass nail, such as is used by  upholsterers for covering chairs,
got impacted with its  point  upwards into the sinus of the ventricle
of the larynx,  and  with its head downwards below the glottis, and
soon terminated in death, notwithstanding the operation of tracheot-
omy by the  surgeon, Mr. Richeley (Dublin Med. Journ., vol. XXV.,
1844, p. 516,)  asphyxia unfortunately having taken  place before sur-
gical relief was  sought for.   No mention is made of exploration  of
the larynx.
   In confirmation of the above case, in which a fiddle peg remained for
so long a time in the trachea, and also in proof of the necessity of our
being on our guard against any hasty inference that no foreign bodies
have been introduced, or that they have been discharged, merely be-
cause the suffocating paroxysms are immediately arrested by the swal-
lowing of any liquid, we may remark that a similar, but much less ag-
gravated case occurred to Dr.  L. Pagen, (see  M. Capuron, in Arch.
Gen. de Mid., 3d ser., t. VII., 1840, p. 369,) of France.   A young
child while playing with some beans, got  one into the larynx, which
caused symptoms of suffocation, but which were immediately calmed
as if by enchantment, by giving it a  tea-spoonful of olive oil.  This
remedy succeeded in  the same manner,  as often as the paroxysms
supervened, until finally, at the expiration of forty days, the bean was
expelled  in fragments,  by the efforts  of the child itself.   Where pa-
tients or  parents will not submit  to an operation, and where the dan-
ger is not imminent, we are thus at least furnished with a temporary
   vol. hi.                  20 
154
NEW ELEMENTS OF OPERATIVE* SURGERY.
 resource of great value, and which may in fact aid in accomplishing
 the ultimate spontaneous removal of the difficulty.
   M. Petel, who has been (see Arch. Gen. de Med., 3e ser., t. XIII.,
 1842, p. 361, 362) one of the earliest advocates  for tracheotomy as
 an extreme remedy in  croup, and who cites three  cures which he
 effected by this process, prefers for the operation the bivalve canula
 of M. Gendron, as modified by him.  (Journ. des Conn. Med.  Chir.,
 October, 1841.)
   Of late years many efforts have been made to introduce or revive
 tracheotomy for croup by MM. Bretonneau, Trousseau, and others,
 (see Valleix in Arch. Gen., Oct. 1844, p. 256,  et seq.)  The operation
 will not be sanctioned  in our opinion, for  the  following reasons:
 1. As it cannot properly be substituted in the first stage, for a vigor-
 ous plan of antiphlogistic, emetic, and revulsive treatment, (viz., ve-
 nesection, large  blistering, leeching and emetics,)  it will be had re-
 course to only in the last stage,  merely to prevent immediate suffo-
 cation, and thus prolong life for  a few hours.   2.  Because it is  an
 operation  which  is  generally contra-indicated,  and properly pro-
 scribed under any  circumstances, or  in any disease  whatever at the
 period of infancy, or that when  croup mostly occurs.  This is be-
 cause of the danger of either laryngotomy or tracheotomy, in them,
 as the smallest drop  of blood passing from the incision into the tra-
 chea has been known to produce immediate strangulation and death.
 This accident is the more to be  dreaded from the great vascularity
 of the parts, and the extreme distension of the veins, and therefore
 more abundant hemorrhage caused by the  cries and struggles of the
 child during the operation; showing how incorrect it is in a surgeon
 of Paris to recommend, as has been  done  recently, with the utmost
 nonchalance possible,  such  an  innovation  even  of tracheotomy
 as that of  direct puncture through the crico-thyroid membrane by
 means  of  a trochar, with a  cutting spring forceps inclosed, this too
 with the patient on his back.   3.  Because in  no sense could tracheo-
 tomy be justifiable as a remedial measure for  croup, because in the
 first stage it would necessarily aggravate  the symptoms, and again
 in the second stage, after the formation of the finger ofglove-like tubu-
 lar membranous prolongations into the bronchi and their ramifica-
 tions, death could not possibly be averted by it.   In illustration of the
 above remarks, we refer to the remarkable case of the successful ex-
 traction of a shawl-pin from the trachea by Dr. Mott.  (See Infra.)
   M. P. Jousset had already (Arch. Gin., 4e ser., t.  V., August,
 1844, p. 402—416,) done full justice to the  subject of tracheotomy in
 croup.   As interne at that time in the Hospital des Enfans, at Paris,
 he had admirable opportunities of demonstrating the true character
 and structural ravages of croup and the inefficacy of surgical means.
M. Jousset shows that the operation under  the name of bronchotomy
 was performed at the remotest period of  time, and for croup under
the name of angina gangrenosa.   Hence the mistake of the moderns
in thinking the  disease  and the operation  both new,  whereas M
Jousset clearly shows, that our own  countryman, Dr. Samuel Bard
 (lb., p.  401,) of New York, had  many years since satisfactorily de-
monstrated that as  respects the disease, the  angina gangrenosa of
the older authors was identical with croup.   Out of 219 cases of the 
BRONCHOTOMY.                      155
operation, from 1782 to 1844, as collected by M. Jousset, it is ascer-
tained that 40 only terminated in  cures ;  while he has verified from
the time of Galen to the present epoch 35 cases of croup or angina,
which  recovered by medical treatment  exclusively, and that even
after the expectoration of false membranes, of which 35, ten were
cases in which false tubular membranes themselves were discharged.
The practice of Van Swieten therefore, in favor of early tracheotomy
in croup, undoubtedly the most rational period, and that of Louis, who
after him considered it the only cure at any stage of the disease, as
well as the modern advocacy of the operation, are wholly and vehe-
mently proscribed by M. Jousset, except as an extreme and last resort
to prevent immediate suffocation.   In two such cases even it was in
his hands followed by a cure.
   Tracheotomy in Spasmodic Dyspnea from  Bronchocele.—Dr.
Handyside, of Edinburgh, (Cormack's Monthly Journ., &c, Jan.?
1845, p.  30, &c.,) in the case of a young man, aged  18, with hyper-
trophied  condition of the thyroid body (bronchocele,) to great ex-
tent, causing distressing attacks of dyspnea and bronchitis, obtained
immediate relief by cutting down through the right portion of the
diseased gland to the trachea, which was displaced by  it, and insert-
ing a tube in the opening made into the windpipe.  The profuse ve-
nous hemorrhage however, which followed, and which it was found
difficult to restrain, had no doubt  much to do in this  case in  allaying
the pulmonary disease, and in promoting free muco-purulent expec-
toration, and  ultimately, in about two weeks a cicatrization of the
wound  and  almost total  absorption of  the enlarged thyroid body.
The case however is one of much interest surgically, and the opera-
tion was the true cause of its successful termination.
   Spontaneous Expulsion of Foreign Bodies from the Air Passages.
—In addition to the well-attested  cases of the length of time during
which such bodies may be retained in the trachea or bronchi, caus-
ing there chronic inflammation, and purulent or bloody expectoration
for two or three years, and then be finally expelled by efforts of cough-
ing, we  may mention that of a  man aged 42, mentioned by Dr.
Duncan  and  Dr. Spence, (Northern Journal  of Medicine,  Aug.,
1845.)  This person letting slip two pieces of bone into his trachea
while at dinner, in February, 1841,  became affected with the symp-
toms as above described, which continued till March 2nd, 1845, when
during a violent paroxysm of coughing he  expelled  the foreign bo-
dies, one of which was rhomboidal and  an inch long, and the other
a slender fragment of nearly the same length.  By June of the same
year he had perfectly recovered.   In another case, a boy aged 5^
years, while chewing an ear of grass in a field, got the same into his
trachea in 1840, when he was attacked with the usual inflammation
and expectoration of pus and blood, which finally threatened hectic
fever, until during a violent fit of coughing 22 months afterwards, the
foreign body was  expelled.   It  was an entire ear of the crested
dogstail grass.  The boy recovered perfectly, (lb., loc. cit.)
   M. Ehrmann, of Strasbourg,  (Arch.  Gin., Mai, 1844,) had  re-
course, with success, to an incision into the trachea  in a woman, for
the purpose  of extracting a fibro-cellular polypus, the upper part of
which had extended up between  the lips of the glottis.  The whole 
156          NEW  ELEMENTS  OF OPERATIVE SURGERY.
 length of the lower left ligament of the glottis was closely grazed off
 by the bistoury.
   Foreign bodies in the  Pharynx.—Mr. R.  Jackson, (Edin.  Med.
 and Surg.  Journ., July, 1843,) describes a case of suicide in a
 woman, aged 42, who designedly swallowed a key, which lodged  be-
 hind the glottis, with its ring part downwards.  The severe inflam-
 mations in the air passages, with the abundant  expectoration which
 ensued, but without deglutition being much interrupted by the foreign
 body, caused death in a few weeks.   A very similar case occurred
 in a man named Gilbert. Dr. Handyside, also, has given cases (lb.) of
 foreign bodies lodged in the pharanx ; in one  the body was rejected
 during a paroxysm of vomiting.   (See notes under the  head  of
 Oesophagus.)
   Pharyngeal Fistula.—Professor Albers, of Bonn, had the rare oppor-
 tunity of examining (see Graefe's und Walther's Journal, Bd. XXX.,
 Heft 3 ;  also Arch. Gin. de  Med.. 3e ser., t. XIII., pp.  489, 490,
 491,) in the  year 1841, a case  of pharyngeal fistula, immediately
 above the os hyoides, near the angle of the jaw, two inches in height
 and one in breadth, in  a German  soldier, aged  41.   It was caused  by
 a sabre wound, in the  campaign of the French  against Constantine,
 and, except  for the first few weeks, during which its  edges were
 cicatrizing, had not prevented him from following the active life of a
 soldier and engaging in other battles, in some  of which he has been
 again wounded.   He wears a leather strap over the fistula, and with-
 out this  can neither swallow, articulate, or cough.   When it is  re-
 moved, he breathes through this large/aperture only, and a good op-
 portunity is then afforded of observing the  position and play of im-
 portant parts in life and  robust health, as that of the velum and
 arches of the palate, the epiglottis, glottis, larynx, &c.  No attempt
 appears to have been made to cure the  deformity.
  Bronchial  Calculus.—Dr. S. C. G. Tice  describes, (Medico-Chi-
 rurgical Trans., vol. XXVI., London, 1843,8vo.) an interesting case
 of bronchial calculus, the symptoms of which  were pain in the right
 side, increased by pressure over the liver, dyspnoea : finally, suffoca-
ting paroxysms of cough on lying down, great fetor of  breath, end-
ing, after a continuance of six weeks, in laryngitis and sudden death.
 There was nothing before this event to indicate the true nature  of
the disease.  On examining the body, an abscess, of the size of a pullet's
 egg, was found in a mass of enlarged bronchial glands at the bifurca-
tion of the  trachea.   It opened into  both bronchi, and into the
oesophagus, and contained a quantity of calcareous matter, some  of
which was hard  and some of soft consistence.  A hard  triangular
 portion was firmly wedged in the aperture,  communicating with the
right bronchus.  This was found to consist of phosphate of lime.  (See
 also British  and Foreign Med. Rev., vol.  XVIIL, July—October
 1844, p. 365.)   T.]

           Article II.—Catheterism of  the Larynx.

  Catheterism of  the larynx,  whether in new-born infants  or at any
 other epoch of life, is  too simple an  operation to require  to be de-
 scribed more in detail.  While with one hand the instrument is con- 
CATHETERISM  OF THE C3S0PHAGUS.
157
ducted through the nose, or what is better, through the mouth, some
of the fingers of the other hand, directed upon the lower part of the
throat, secure its extremity, bring it into the glottis  and prevent its
passing into the  oesophagus.
                        CHAPTER  IV.

                    ALIMENTARY PASSAGES.

          Article  I.—Catheterism of the (Esophagus.

   Various kinds of affections may render it necessary to  have re-
course to catheterism of the oesophagus. It is employed either as an ex-
ploring, extracting or propulsing remedy; it becomes an indispensable
operation when we have to penetrate into the stomach to give relief in
cases of certain poisons, or to force into this organ artificially, either
aliments or medicated  substances, and it may be of some advantage
also in the treatment of certain diseases of the oesophagus itself.  Its
manual is easy and within  the  capacity of  any one.   It  may be
accomplished through the nose as well as by the mouth, by means of
metallic  instruments properly curved, and  especially with flexible
rods, such as canulas, gum-elastic bougies, whalebone, &c.

                    §  I.— Through the Nose.

   The first method, or that which consists in entering  through, the
nasal fossae, and which was adopted for a long time as the preferable
one, is at the present  day almost entirely abandoned.   Being fre-
quently difficult, and always fatiguing to the patient, it should be
reserved only as an exceptional method.  If the catheter is inflexible
(fixe) its curvature will  scarcely allow it to go beyond the apex of the
pharyngeal cavity, and consequently to penetrate into the oesophagus.
If it is flexible and  straight, it buts against the vertebral wall of the
posterior fauces, in  such manner as to make it sometimes difficult to
disengage it.  This route however is better than none, should the other
not be practicable.   The sound, held in the right hand as a writing
pen, is introduced through the nares in the  same manner and with the
same precautions as for  catheterism of the Eustachian tube, except that
the concavity of its beak, in place of being turned outwards or inwards,
is rather to be directed downwards.  By means of the forefinger or
a blunt hook glided into the mouth, the operator endeavors to reach
its extremity as soon as it arrives in  the upper part <5f the pharynx;
depresses it a little  with the left hand, while with the right he con-
tinues to push it forward;  in this manner directs its point into the
axis  of the oesophagus, while  avoiding with care the entrance of the
larynx or making too  much friction  on the parts; penetrates and
advances  by degrees;  stops upon encountering  the  slightest diffi-
culty ;  changes a little  the direction of the force applied; withdraws 
158
NEW ELEMENTS OF OPERATIVE  SURGERY
the instrument  slightly in order to push it in again in another direc-
tion, if he meets with any resistance, and descends to a greater or
less depth according to the indication he  proposes to fulfill.  Upon
the supposition that a straight elastic catheter should have occasioned
some embarrassment, nothing would  be more  easy than to remedy
this  inconvenience;  it should be passed down to a line with  the
glottis  by means of a curved stilette, which  should then be  with-
drawn, leaving  the catheter in and proceeding in such manner for the
rest of the operation as above described.

                      § 11.—By the Mouth.

  Whatever may be the mode adopted, the patient being seated  on
a chair, is to be supported  as in  all  other operations which are per-
formed upon the face.  When he enters  by the mouth  the surgeon
gently  depresses the tongue with the left forefinger, which he  intro-
duces, if possible, as far down as to the epiglottis, in order to protect
him  against the deviations of the instrument  in the direction of the
respiratory passages, then causes the sound or catheter to glide along
the radial border of this finger while following the dorsal surface  of
the tongue ; enters without difficulty into the oesophagus if it presents
the slightest curvature;  secures  its  extremity  with the finger in  the
contrary  case in order to compel it to follow  the axis of this canal,
and finally  forces it to take  such  course as he judges most suitable.
  When  circumstances require  that it should be kept in its place
after the operation, it is to be inclined  to one side  in  the interval
left between  some of the  teeth, should any have been extracted,  in
order that we may  adjust it at  one of the labial  commissures, by
means of a ribbon which is to be fastened moreover around the head.
Though  it  has  been introduced  by the mouth, should its presence
cause too much fatigue to this cavity, nothing  would prevent us, as
has been remarked by Boyer,  from bringing its outer extremity
through the nose and thus changing the organ.  All  that would  be
required  for this purpose, when it is  once placed, would be to secure
it by means of Bellocq's sound  or  any  flexible bougie whatever,
introduced  through the nose, and to make traction upon it bv means
of a thread previously fastened to its extremity, in the same'manner
as would be  done in tamponing the nasal fossae.  Unless the oeso-
phagus should be deviated, contracted or  abnormal, its catheterism is
in general very simple.  We should incur no risk of wounding  its
walls, making a false passage or blundering, in  a word, or perforating
it, as happened  to  the surgeon mentioned by Chas. Bell, unless  we
should  proceed with extreme imprudence or use a  degree of force
that no instructed  surgeon would attempt to  employ.   The  finger
being charged to guide the catheter as far down as to beyond the epi-
glottis, there can be no difficulty  in  ascertaining whether it has not
accidentally descended into the larynx, as appears to  have happened
in the case mentioned by Worbe.  Presenting a light at the orifice
of the instrument, or the impossibility almost of its penetratino- lower
down than  on a line with the bronchi, or better still, the injection of
a few drops of liquid, which in that  event would not fail to brinf  on
cough, &c, would  moreover soon assure us of the fact. 
contraction  of the oesophagus.
159
                             § III.

 •The presence of an instrument in the oesophagus is not supported
with ease by all persons.   In some it produces a desire to vomit, a
considerable  degree of acute irritation and  sometimes even  fever.
If still more serious accidents result from it; however useful it may be,
it is to be withdrawn to be introduced subsequently, should there be
occasion for it.  One of its most serious inconveniences, though au-
thors have scarcely made mention of it, consists in my opinion in this,
that either by its beak or the convexity which we  have forced it to
take, it necessarily makes a greater pressure upon some points of the
posterior wall than upon any of the others.  This pressure, however
slight it may appear to be, being uninterrupted, is calculated to cause
at first a purulent exudation, then an ulceration or eschar, and finally
a perforation.  It would be difficult to call in question the possibility
of such dangers,  when we know that they have been  produced in
more than one instance by the extremity of a simple gum-elastic
sound acting on the rectal wall of the urinary bladder.  I strongly
apprehend moreover, that the patient, whose  oesophagus was found
destroyed  to  the extent of at least two inches at an inch and a half
above its passage through the diaphragm, and who  had  been treated
by means of dilating sounds with  apparent success, by M. Carrier,
was in truth the victim of such an accident.

          Article II.—Contraction  of  the Oesophagus.

   Since  Mauchart has demonstrated the analogy which exists be-
tween the coarctations of the urethra'and those of almost all the  mu-
cous canals, surgeons have endeavored at different times to apply to
the contractions of the oesophagus, most of  those remedies which
have  been found useful  against those of the excretory duct of the
urine.  Mechanical dilatation was one of the first which was ventured
upon.  Recommended by Richerand and Dupuytren ;  made trial of
on one occasion by MM. Carrier and Jallon, in a merchant of Orleans,
who got along very well with it  for more than a month, but ulti-
mately perished from a destructive ulcer in the oesophagus ; employed
by Boyer, in  the year 1797, in  a woman who  experienced but slight
advantages from it, and by M. Sanson on a patient who, after having
obtained much benefit from it, was desirous of leaving  the  Hotel
Dieu, and considered it no longer necessary to continue under treat-
ment ; it appears to have been  attended with a completely success-
ful result in a case of Migliavacca,  cited by Paletta ; in another of E.
Home ; a third of M. Earle ; a fourth of M. Mcllvaine, and a fifth
of M. Denis, (Journ. Hebdom., 1835, t. II., p. 5.)  Catheterism is the
process used.   The  bougies, whether emplastic, elastic or  conical
rather than cylindrical, or better still, hollow sounds  denominated
aesophagean, used in such manner that their  size may  be gradually
augmented, should be manipulated  in these cases with the same cau-
tion and prudence as when used in the urethra.  But the canal being
larger or being intended to receive greater dimensions, the size that
we are soon obliged to give to  these instruments has placed us undei
the necessity of substituting other contrivances for  them. 
160
NEW ELEMENTS OF OPERATIVE  SURGERY.
  A contraction produced by an abscess which  had left an oesopha-
geo-tracheal  fistula, was cured by  M. Gendron, (Ibid., 1830, t., I. p.
378,) by means of a dilating sound  sprinkled with alum.  The author
upon the strength of this fact  and another, which was communicated
to him by M. H. Berard, (Journ. des  Conn. Med-Chir., Nov. 1837,
p. 175, 187,) proceeds to lay it down  that  contractions  of the oeso-
phagus ought to be treated,* and may be cured by catheterism.   The
instrument of M. Fletcher is curved and slender, and of metal, and
consists of three branches, which a central rod provided with a head
enables us to approximate or separate at pleasure.   After having in-
troduced it like an ordinary catheter, beyond the point of coarctation,
it suffices to cause  its movable axis to ascend, to enable the surgeon
to separate its branches gradually to the extent that he may judge de-
sirable.   However ingenious this instrument may appear, it ought to
be rejected.  It is by means of a uniform  pressure, and not at three
points only of the contracted periphery, that dilatation can offer any
prospect of success.  It is necessary before all other things, that this
indication should be perfectly fulfilled, but M. Fletcher appears to have
entirely overlooked it.   The air dilatator of M. Arnott, or the flexible
and  sheathed  meche-holder contrived by  M. Costallat, in order  to
reach deep-seated coarctations of the rectum, and especially of the
urethra, would  have a decided preference over it.    Many surgeons
also  have  turned their  attention  towards cauterization.   Though
among us this  mode of treatment has been  rarely made trial of, and
that  Boyer has thought proper formally to proscribe it, it is not how-
ever the same in other countries.  M. Mondiere, (Arch. Gen. de Med.,
2nd ser., t. I., p. 465, t. II., p. 504, t. III., p. 28,) in fact shows that in
Italy, England, and America, it has been several times had recourse to.
A flexible rod, wrapped in linen saturated with liquid caustic was in-
troduced by Paletta as far  down as to the stricture, and the patient
who died some weeks after found himself at first relieved by it.  E.
Home properly rejecting every substance  of a fluid  character, pre-
ferred nitrate of silver,  and used it in seven instances.  Four of his
patients were cured, and the three others died from the natural pro-
gress of their disease.   Out of three cases published by M.  Andrews,
one only succeeded.   In the two others the treatment could not be
continued.   Finally,  MM. C. Bell and Macllvaine also declared
themselves its partisans  as Darwin  had previously done, and appear
to have  made use  only of nitrate of silver.   A  difficulty which
first  causes us to hesitate, is  that of ascertaining the nature of the
contraction which is to be overcome.   Those only which arise from
chronic phlegmasia,  or  an induration  or lardaceous transformation
of the mucous tunic or suprajacent  membrane, admit of  the employ-
ment of cauterization ; but how are these to be distinguished from le-
sions which may be  produced by  tumors, cancerous or fungous  de-
generescences, ulcers of all  kinds, aneurisms, polypi,  &c. ?   The
urethra being, so to speak, liable only to the first, incurs the risk of
no embarrassment of this kind.   Its small diameter, superficial situa-
tion, and the arrangement of its walls moreover, renders its mechani
cal dilatation an easy matter,  and unattended  almost  with any dar
ger.   The oesophagus being surrounded with pliant tissues, and bein»
itself exceedingly dilatable, "is far from possessing the same advanta- 
contraction  of the  cesophagus.
161
geous conditions under this point of view.  By widening the contrac
ted  part, bougies scarcely  do  any more  than  to push outwardly
the projection which was tending  inwardly, and the disease returns
almost as soon as the use of the instrument is suspended, making  it
therefore only a palliative treatment.   As to the nitrate of silver,  I
would use it much less  in its  character  as a caustic, than  with the
view of  modifying the morbid condition of the parts ; in this respect.
the exactitude with which it is applied to this or  that point in prefer-
ence to another, is of less importance than is supposed.  This, more-
over, is a question which will be treated of under the head of diseases
of the urethra.
   [Organic Stricture or Contraction of the Oesophagus.—This dis-
tressing  disease, which  usually ends in a slow death by inanition or
starvation,  has naturally engaged  much  attention.   M.  Gendron
furnishes one of the most interesting cases of cure of this disease,
obtained  by perseverance under every obstacle  of the processes of
alternate dilatation and cauterizations with alum and nitrate of silver;
the  dilatations being effected  by the ordinary whalebone  probang,
made very flexible, with spherical sponges on their extremity of  6
to  7 centimeters in  diameter,  and the cauterization  by the  gum
elastic canula with the wax border, to protect other parts than the
structure itself from the action of this substance.  The patient,  a
gentleman 33 years of age, had been for near two years the victim
to distressing suffocating  spasms in  the throat and gullet, accompanied
with still more annoying and  prolonged attacks of eructation after
taking his food.  Finally, he could swallow  nothing but soft-boiled
meat, and scarcely  a drop  of liquid.  The necessity of abstaining
from nourishment soon wasted him away, and the thirst tormented
him with agony.   M. Gendron, (see Arch. Gen. de Med., 3e ser.,
t.  XV.,  1842, pp. 448, 457, also  cases by the  same author  in the
Journ. des  Connaiss. Medico-chirurgicales  de  Paris, Nov.  1837,)
by  the probang, and especially by aiding  this instrument with his
fingers in the pharynx, whenever the sponge was  stopped and the
whalebone bent on encountering the impediment, succeeded in locali-
zing the  seat  of this latter behind  the first ring of the trachea.
Meanwhile  great relief  was obtained by introducing any kinds of
liquid food through the canulas used.  The proof that duplicatures,
as well  as  a firm bridle existed  at the point,  was shown by the
greater difficulty of  swallowing liquids, as  these are caught by such
folds in the lining membrane.   The caustic brought away the debris
of the  abnormal  obstruction,  and  the patient was after a  long and
resolute course of treatment by the instruments in question, restored
to excellent  health, enborn point and cheerfulness, but still was under
the necessity  of persevering  in the catheterism with the probang
twice a week, to keep up the calibre of the passage to its normal
dimensions.   The flatulence, spasms, &c. were wholly removed.  It
is a singular  feature  of these  circumscribed strictures, that they are
unaccompanied with any defined pain in the part or vicinity.  Though
with most surgeons catheterism and  cauterization  of the cesophagus
have been considered of late, to be  more hazardous and injurious than
useful, there can be  no  doubt, judging  by  the details  given  by M.
Gendron, that much of the disrepute into which they have fallen has
  vol.  m.                      21 
162
NEW ELEMENTS OF OPERATIVE SURGERY.
 arisen from the imperfect manner in which they have been perform-
 ed ;  and that if practised as perseveringly and with as much appa-
 rent judgment, caution and tact as they were in the remarkable case
 in question by that  surgeon, they will claim a yet higher reputation
 than they have hitherto  reached, in a disease, which without some
 such  surgical resource  must  necessarily end  in a  frightful death.
  The oesophagus sometimes becomes preternaturally dilated, as in the
 case related by Dr.  Lindau of Thorn, (Casper's  Wochenscrifft, 1840,
 No. 22,) in the form of a pouch occupying all  its middle and poste-
 rior portion, and no less than  four inches in diameter at its largest
 expansion, the whole of this sacculated diseased mass being adherent
 to the surrounding parts.  Whether such pouches  be the  result, in
 the first place, of cancer, and  then a  constriction interrupting the
 food, and thence giving rise secondarily to dilatation from the efforts
in deglutition ; or whatever the cause may be, it will be found that
one diagnostic mark will present itself after the  dilatation is com-
plete, which is the reverse of what we have seen in the case above.
Thus, in dilatations it will be the most liquid kinds of food which
will make their way most readily into  the stomach, while  the solid
portions from the absence of  propulsive power in the tube  will con-
tinue to accumulate in the pouch.  T.]

        Article III.—Foreign Bodies  in the CEsophagus.

  A  crust of bread, a piece of tripe,  large mouthfuls of hard and
tough meat or skin, a slice of fruit, a sugar-plum, a piece of mutton,
cake, a  slice of ham, an entire egg, a chesnut, pear, fig, and all other
substances that may possess some solidity, and which belong to arti-
cles of  food, or that are sometimes introduced into the mouth, may
be arrested in the cesophagus and give rise to serious accidents.  As
these different bodies, however, are more or less soluble in the excre-
tions of the digestive passages, it rarely happens  that  they do not
ultimately descend into the stomach.  Pebbles,  pieces of glass, a fish
or other small bone, a piece of money, a blade of a knife, a fork, and
a thousand different modifications of foreign bodies, so many instances
of which are  contained  in the memoirs of Hevin and Sue, are infi-
nitely more  dangerous,  though the organism has  in more  than one
instance got the better of them without any  assistance.  They lace-
rate  or  contuse the parts, produce inflammations, abscesses and
frightful pains, which frequently end only in  death.  To the numer-
 ous facts which are already contained in authors, we  could, without
the slightest difficulty, add a multitude of others.   MM. Gilbert and
Corby,  (Arch. Gin. de Med.,  t. XVII., p. 139,) Murat, Bard,  &c,
have also added many to the list, and practitioners daily encounter
new instances.  The aorta was in this manner perforated in the cases-
mentioned by MM. Laurencin  and  Leger or Martin, by a piece of
six livres.   It was  the pulmonary artery in the patient of M.  Ber-
nest, and the trachea in the case of  Dupuytren, (Begin, Journ.
Hebd., t. II., pp. 93—124.)  Routier, (Bull, de la Fac, t. IV., p. 499,)
speaks of a five franc piece which having become implanted in this
manner, caused death at the expiration of a month.  Dumortier has
in this manner seen the presence of a piece of money arrested in the 
FOREIGN BODIES IN THE C3SOPHAGUS.
163
oesophagus cause a perforation of the primitive carotid artery.  When
it is evident that  the presence of these foreign bodies may produce
injury, and that the organism alone is  incapable of relieving itself of
them, three classes of resources may  be had recourse to before pro-
ceeding  to  the section of the cesophagus.  They are to be pushed
down into the  stomach, or obliged to return by the natural passages,
or we restrict ourselves to preventing,  or combatting even with active
means, the accidents they may give rise to should they already exist.

                        § I.—Propulsion.

   We should force into the stomach only those foreign bodies which
would be attended with too much difficulty to extract by the mouth,
but which having been once got out of the cesophagus will be some-
what less dangerous to the  patient.  Water  swallowed  in  large
quantities, large mouthfuls of the crumb of bread, beef, biscuit, or figs
turned inside out, prunes deprived of their pit, portions of sponge with
a thread  fastened to  them, long  bougies besmeared with oil, a leek,
slight strokes upon the back with the  fist, as recommended by  De la
Motte,  and which common people rarely fail to have  recourse to,
together with  I do not know how  many other remedies, have been
proposed and  successively employed  in practice with more or less
decided  advantage, and frequently  also without  any kind of benefit.
In such  cases  the leaden  rod of Albucasis and Rhazes, a ball of the
same metal  melted and  attached to  the extremity of a rod  of iron,
silver or brass, and which was so  much eulogized by Mesnier,  the
silver rod of Verduc terminated in  an olive point,  and the curved
sound, &c, are  far also  from being  always attended with success.
In all these I  see only the stalk of the leek, which has been quite
generally employed since the time  of M. Pare,  and  the leaden ball,
which  are really worthy  of any confidence.  It will also  be neces-
sary that those two kinds of means should be supported by flexible rods
capable of following without difficulty the tortuous shape of the mouth,
pharynx  and cesophagus, while possessing at the same time a sufficient
degree of solidity not  to break during  the operation.

                       § II.—Extraction.

   When we  cannot reach the foreign bodies lodged in the pharynx
or oesophagus  by  means of the fingers, we must have recourse to a
long forceps slightly curved, or for example to  the urethral forceps
of Ravaton,  erroneously denominated Hunter's forceps.   The species
of tenaculum or hook of iron wire of Riviere, (Bonet, Corps de Med.,
t. IV., p. 150,)  or  Perrotin, incurs the risk of lacerating the tissues
when it is withdrawn,  as occurred to Petit of Nevers.  Stedman, by
terminating it with a button, has evidently improved this instrument,
and Dupuytren, who  replaces it by a long silver stem terminated in
a ball at  one end and a ring at the other, and who makes it an explo-
ring instrument or species of catheter  in straightening it, and a hook
in curving it, has rendered it still more easy of management.
   A. F.  de Hilden's hook, in  the form of a scraper, would be  much
more dangerous.   That which Petit contrived, with a double flexible
silver wire, turned into a  spiral form,  and  curved towards its noose, 
164
NEW ELEMENTS OF OPERATIVE SURGERY.
 in the  manner  of Pellier's palpebral elevator, has no objection to it
 but its want of strength.  The probe or whalebone having upon it a
 collection of small movable rimjs, which was extolled by the same
 practitioner, and which De la Faye  modified  by restricting himself
 to the use of strands  of flax attached to the small ring of the com-
 mon stilette of the catheter, is also not to be neglected, when the
 body to be extracted  is irregular and of small  size.
   B. A noose of packthread or whipcord, which Mauchart found
 reason to be satisfied  with;—1st, a sponge  strongly  bound with
 a thread, and introduced below the foreign body by means of a large
 leaden canula, at the  end of which it is held, and drawing on the two
 extremities of the thread, which are brought,  one through the canal
 and the other along the outer side of the instrument, as was done by
 Brouilliard ; 2d, the same substance attached  to the extremity  of a
 whalebone, as Willis recommends, or of an ordinary catheter, or that
 leaden, or copper, or  cribbled canula, borrowed from Arculanus or
 Ryff, and modified by Hilden, who, in order  to render it stronger,
 added to it a leaden stylet;  3d, the  sponge in addition,  which
 Hevin  recommends, should  be surmounted by a  purse of cannepin
 or silk, in order to prevent it from swelling before it had descended
 sufficiently  low  down,  which Bonfils,  (Arch.  Gen.  de  Med., t.
 XXIII., p. 530,) as well as Petit, attaches to the extremity of a whale-
 bone, inclosed as far up as to its handle  in a flexible tube, made of
 silver wire, rolled in a  spiral manner, and which Quesnay covered with
 sheep-gut, and Ollenroth hung to  the extremity of a chain chaplet,
 composed of 61 balls  of pewter, might also be applicable in certain
 cases ;  4th, the same remark applies to the species of broom, whip, or
 brush, or  excutia ventriculi, which had  already been mentioned by
 Wedel, Teichmeyer, and Heister, and which the English, who call it
provendor, form by attaching  small portions of scraped linen, or a
 bunch of hog's bristles, at the  extremity  of a whalebone, or brass
 lateen or wire.
   C.  The manner of  using these different instruments, whether for
 the purpose of forcing the bodies in question into the stomach or for
 extracting them,  is moreover  too easily comprehended  to make it
 necessary to dwell any longer upon it.   The same remark may be
 made of their relative value in the different cases where many of
 them  may be advantageous.   It is for the skillful surgeon to select
 which of them is best, the most simple, certain and  least injurious /
 among those which he has at command.  The species of forceps with
 several branches, which is opened and closed by a particular mechan-
ism, before and  after having  seized the foreign body, and which M.
 Missoux in his thesis in 1825 has described under the  name gerano-
rhinque, is, though ingenious, too complicated  to be adopted.  The
crane-beak,  designed  for  seizing  the  foreign  body while  another
curved forceps widens the walls of the canal, employed by M. Gen-
soul (Journ. des  Hop. de Lyon, t. I., p. 233) to extract a  piece  of
of cutlet, would be preferable.  That which M. Blondeau (These, No.
44, Paris, 1830) proposes, and which is founded on the  principle of
litholabes and enclosed in a flexible sheath, would be equally prefer-
able if it was not already in itself  too complex.  The same must be
said of the ingenious apparatus devised by M. Parant  (Trans. Med. 
0330PHAGOTOMY.
165
t. VI., p. 72.)   The small dilating blade of M. Doussault, (These, No.
41, Paris, 1831,) and all those instruments which, after being intro-
duced  shut up, open themselves in the cesophagus in the  manner of
an  umbrella, are  tou dangerous  not  to be replaced by the bladder
that M. Oury (These, No. 290, Paris, 1833) attaches  to the end of a
sound, and does not dilate until  after it has been made  to advance
below the foreign body, should that have  presented sufficient resist-
ance to require it.
                             §  III.

   The efforts of expulsion and vomiting, which  many authors have
advised, should be encouraged, notwithstanding the objections of B.
Bell, whether they consist  in titillating the uvula or the bottom of the
throat, or in gorging the patient with warm water, or by any other
mode, form a last resource, to which we ought not to resort except for
bodies destitute of any asperities or projections, or until after having
made use of the two  kinds of modes above indicated, and in order
only not to have occasion to reproach ourselves for having proceeded
too hastily or without necessity to cesophagotomy.

                 Article IV.—GCsophagotomy.

   Though this operation may not have been formerly proposed by
any person before Verduc and Guattani, it is impossible nevertheless
not to perceive that the idea of it is found in several authors who are
more ancient.  The incision into an abscess containing a  small bone
which  had  escaped from  the cesophagus  and approximated to the
integuments  of the neck, which  had  already been  performed  by
Arculanus and Plater; the fish bones extracted in the same manner
by Houlier and Glandorp; and the opening into tumors more or less
dense or voluminous, which  had become developed upon the same
region, as practised by Kerkring, Rivals, &c, would naturally lead
to this operation.   But wounds  of the cesophagus had,  up to  that
period, been considered so dangerous that practitioners required nu-
merous facts and direct proofs to dissipate their fears  and  scruples.

                              § I.

  Tiie  incision of the oesophagus, performed  for the first  time by
Goursault in 1738, and then by  Roland, (Acad,  de Chir., t.  III., p.
10,  in 8vo, 1819,) is an operation which  is applicable only to two
descriptions of particular cases:  1st, when we wish to extract  a
foreign body which, by its presence in  the cesophagus, compromises
to a greater or lesser degree the  life of the patient; 2d, to introduce
artificially nutritive substances  into  the digestive passages,  and to
prolong to a greater or less length of time the life of  those persons
who are prevented from swallowing by means of a coarctation of the
lower part of the pharynx.  In the first case, before proceeding to
cesophagotomy, we must make trial of every means in order to com-
pel  the foreign  body to be ejected  by the natural passages, unless it
is of such a nature as  to render it  improper to force it towards the
itomach  without  some danger.    Since  cesophagotomy  has  taken 
166          NEW ELEMENTS OF OPERATIVE  SURGERY.
rank among the systematized operations of surgery, it has received,
like almost all the'others, various degrees of improvement.  Guattani,
who was not unaware that the cesophagus is situated* a little more to
the left than to the right of the trachea, advises that we should take
up a  transverse fold of the skin and  incise it from a line with the
cricoid cartilage as far down as to the sternum and upon the left side
of the neck ;  separate the lips of the wound by means of hooks ; and
arrive gradually to the cesophagus, and divide it in a direction paral-
lel with its fibres.  According to B. Bell there  can be no settled
place for the incision, as  it should always be performed upon the pro-
jection which is made by the foreign body.  He knew moreover that
with certain precautions the recurrent nerve could easily be avoided.
  To be more certain of dividing no vessel of any size, Richter re-
commends that the muscles should  be separated by means of an
ivory knife.   The method of Eckholdt, extolled for what reason I.do
not know, by Sprengel, and which consists  in making the external
incision fall upon the triangular space which separates the two roots
of the sterno-mastoid  muscle, appears  to me to deserve the oblivion
into which it has sunk.  I would make the same remark of that of V.
Gescher, (Rust's Handbuch der Chir., t. XII., p. 281,) who recommends
that we should traverse the trachea  to reach the cesophagus from
before backwards.  M.  Chas.  Bell says, that if we place the thumb
on the track of the internal jugular vein, in order to cause it to dis-
tend while we are incising the skin, the platysma-myoides and  ner-
vous  branches  of the cervical  plexus, and that if we separate  the
muscles apart by means of the handle of a scalpel, the oesophagus
will soon  present itself, so to speak, of its own accord, and  that  in
this manner, cesophagotomy is not dangerous; but this author is evi-
dently mistaken in regard to the importance of a precaution of this
kind.   M. Richerand, who only admits of cesophagotomy in cases
where the size of the foreign body is so considerable as  to make a
protrusion beyond  the  surrounding  parts,  and who justly  main-
tains that  it is almost always at the entrance of the canal of deglu-
tition  that  these bodies become arrested, adopts, in every particular,
the process of Guattani or B. Bell.  In this hypothesis, in fact, the
external projection is a guide  which directs with certainty to the
oesophagus, and which favors the pushing aside of all those organs
which it is important should be avoided.  An instrument which was
devised by Vacca  enables us  to effect the same object in all cases.
It  is a long metallic stem, terminated  in a button, and cleft in the
form of forceps at one of its extremities.  This stem slides in a canula,
which has a large opening upon one of its sides at some inches beyond
its extremity.   The complete instrument is introduced, shut up, until it
reaches to below the foreign body.   The surgeon then draws gently
towards him  the forceps, one of the branches of which, acted upon
by its own elasticity, does not fail to get caught in  the lateral hole of
the canula, which served it as a sheath, and thus raises upon the side
of the neck the different  layers which are  to be divided.  But the
dart-shaped sound is infinitely more convenient still than  the instru-
ment of Vacca, if it be  that we require a director when we perform
cesophagotomy.  In raising up all the soft parts to the left, and  in
front,  by  means of the  beak of a  sound, previously introduced 
03S0PHAG0T0MY.                      167
nearly down to the body to be extracted, as proposed by M. Roux,
the carotid artery, jugular vein, and pneumo-gastric nerve are neces-
sarily left posteriorly.   The thyroid vessels themselves, and the tra-
chea, are also sufficiently distant to prevent any danger  in  pushing
his dart-shaped instrument from within outwards, and from  making
use of it afterwards in the manner of a canulated sound, as in litho-
tomy.   Nevertheless  it is unnecessary  to  proceed in this  manner
blindfolded.  Nothing  prevents our dividing at first, layer by layer,
the different  tissues which  separate the cesophagus from  the integu-
ments, and not making use of the sound except in the last  stage
of the operation.   By this process cesophagotomy has no longer any
thing alarming in it, or difficult, and may be performed by every
surgeon.  If it were necessary, in  fact, there would be no objection
in substituting an ordinary sound for that of F. Come.

                    § II.—Operative Process.

   The patient is placed in the same way as for tracheotomy, except
that we  incline his face a little towards the  right.   The  surgeon,
standing up, and  to the left, divides with a straight bistoury the in-
teguments and platysma-myoides,  to the  extent of two or three
inches, upon  the  anterior  border of the  sterno-mastoid muscle, be-
tween the sternum and the larynx, and as much as possible immedi*
ately opposite to the foreign body, the position of which he has pre-
viously ascertained, by means of the blunt-pointed sound of  Dupuy-
tren, the dart sound, or  any other  instrument.   Afterwards  pushing
this  muscle  towards the outside, he lays bare the omo-hyoid and
sterno-hyoideus; pushes them aside in their turn;  tears, by means
of the beak of a canulated sound, or cautiously divides with the bis-
toury the fibro-cellular layers, in the same way as if he were apply-
ing a ligature to  the primitive carotid artery; then raises  up and
pushes inwards and forwards the thyroid  body.   Adopting the same
precautions until he  comes down  to  the groove, which  is  situated
laterally between the oesophagus and trachea, he  there encounters
the inferior laryngeal nerve.
  Having introduced his dart sound through the mouth, he causes its
point to pass  through the oesophagus, as far down as to the bottom of
the wound ; secures it with the thumb and left forefinger; requests an
assistant to push forward its arrow; directs the point of his bistoury
upon the grooved concavity of this stem, and immediately makes an
incision into the cesophagus, proportionate to the size of the body to be
extracted.  When we do not employ a director, we must  first open
into the canal on its side by a small puncture, which  enables us im-
mediately to  introduce a canulated sound into its interior, and after-
wards to enlarge its wound by means of  a bistoury or blunt-pointed
scissors.   If the substance to be removed does not present  itself at
the opening which has just been made, we must proceed to search for
it by means of forceps or  any other appropriate instrument.   The
wound may be united by first  intention.  If an  arterial branch of
some size has been wounded, a ligature is to be applied to it.   A gum
elastic catheter must be introduced through  the nares or mouth, as
far down as into the stomach, and not be withdrawn from it before 
168
NEW ELEMENTS OF OPERATIVE .SURGERY.
the third or fourth day, in order that  the  aliments  and drinks may
not in any manner interfere with the agglutination of the wound of
the cesophagus,  or escape into  the tissues  of the  infra-hyoid  re-
gion.   If oesophogotomv, performed  on  the thirtieth day  by M.
Arnott, (Gaz. Med.. 1834, p. 45— Med. Chir. Rev., July,  1833, p. 240,)
to extract a portion of the vertebra of a sheep, caused the death of
the patient  at the expiration of three  days,  two patients that were
operated upon after these precepts at the Val-de-Grace by M.  Begn,
(Journ. Hebd., i. XL, pp. 94, 111, 124,) one on the eleventh day,and
the other on the  sixth, in order  to extract a piece of  bone, were per-
fectly restored.

                             §  III.

   The anomaly pointed out by MM. Steadman, Kirby, Hart, Gode-
man, and Robert, as well as by myself, of a carotid or subclavian pass-
ing around the cesophagus in the manner of a spiral,  or gliding under
its vertebral surface in order to reach the side of the  neck, would not
expose to any dangers unless the  operation should be performed very
low down.
   [An iron-cellar key four inches long and one in breadth at either
extremity, got lodged in the upper part of  the cesophagus, and  there
remained for the space of 58 days, giving rise to the  supposition only
of a protracted  tracheo-bronchitis, wasting away the strength, and
not materially interfering with the swallowing even of hard  solid
food.   This occurred in  the case of a woman aged 42, described
by Dr. R. Jackson of Leith, (Edinb. Med. and Surg. Journ.,  July,
1843,) the woman  having designedly swallowed  the key to destroy
herself, yet persisting in denying it to her death.   The  block of the
key was found resting close to the epiglottis and on the hyoid bone,
the shank  of the key and ring lying downwards in the cesophagus,
the ring  having caught in a fold  of  the  lining membrane of this
tube, and which  fold constituted  a  sac for it.  Some thickening  of
the tube  was apparent,  and a few slight  ulcerations.  Death was
here caused by irritation of the air-passages,  not by  dysphagia.
  Dr. Antony of Philadelphia,  (Philadelphia  Med. Examiner, April,
1845,)  ingeniously removed a fish-hook lodged  in  the gullet, (and
which a boy had mischievously dropped with its line into the throat
of an old lady while she was  asleep,) by saving a portion of the
line, and passing down by this means upon the hook a bullet drilled
through the  middle.  Then passing down upon this  bullet by means
of the same string a hollow reed, the hook and bullet were withdrawn
through the  reed without any injury to the  parts.
   Foreign Bodies  in the Integuments, Eye,  SfC—Dr. Bachelder of
this city, (see Collins's New York Medical and Surgical Reporter,
June  27,  1846,  p.  303, &c.,) in  cases of needles, fyc in  the palms
of the hands and soles of the feet, operates with great success in the
following manner:
   " The operation  to which I allude, and which, as I have said before
and now repeat with emphasis, I have practised with uniform suc-
cess, is to make two incisions, which commence in  a point  a little
distance, say a quarter of an inch, from the  place where the needle 
03S0PHAG0T0MT.
169
entered, and  diverging on either side of the place of entry,  and
dissect up the triangular flap, whose base and sides should be about
five-eighths of an inch long.  It is best that the  point whence they
diverge  should be longitudinally in a  line with the  place  of entry,
and on the proximal or distal side of it, according to the  supposed
direction in which the needle entered or lies.  These incisions, which
should of course correspond as nearly as circumstances will admit,
with the longitudinal direction of the member, may be carried down
to the  palmar  or  plantar aponeurosis, and indeed through either if
necessary, with safety ; for the blood-vessels and nerves lie beneath
those membranes:  and the dread of wounding the fibrous tissues of
these parts  has long since ceased to  haunt the imagination of the
surgeon.  As the resistance of those aponeuroses causes the fracture
of the needle in most instances, to happen just exterior to them, you
will generally need only to dissect and turn back the triangular flap
of integument, ana tnen  if requisite,  remove with  the  dissecting
forceps and scissors tne cellular substance which intervenes between
it and  the aponeurosis, in order to feel and extract the foreign body
with the fingers or forceps.   If you do not succeed, the aponeurosis
itself may  be treated  in  the same manner  as  the tegumentary
covering.
   "As needles and pins have remained many years in the  system—
have travelled in all directions, and been found in almost every part
except the  brain, without having caused much harm or serious in-
convenience, the question might be asked whether it is best to inter-
fere at all, or  let them remain and take their  own  course ; to this
interrogatory I would reply, that  I have also known  many cases in
which they were productive of very serious mischief, by undermining
the general health, and nearly, if not quite depriving  the patient of
the use of the limb ;  therefore always  remove them in the first  in-
stance if practicable."
  M. Castelnau (Arch. Gen.,3e ser., t.  XV., p. 210, &c.,) relates the
extraordinary case of a man, who for three years and a half retained
a sharp, triangular fragment of iron, 13 millimetres in length, in the
globe of the eye, without producing any other effects  than severe
pains in the  organ, but not until two years after the injury occurred.
It then  made  its way, but  without any suppuration, to the cornea,
where it occasioned intense conjunctivitis.   It  was  readily  ex-
tracted, when the accidents immediately ceased.   The absence of the
suppurative  process noticed by M. Velpeau in the text, as  the usual
consequence of metallic fragments in the globe, is, when taken into
connection with the unprecedented size of the foreign body,  and its
comparative innocuousness for so long a period, a remarkable  feature
in this  case. T.]
  vol.  in.                      22 
170
MEW ELEMENTS OF OPERATIVE SURGERY.
PART  THIRD.

    THE CHEST.
                         CHAPTER I.

                           TUMORS.

     Article  I.—Tumors and Extirpation of the  Breast.

                       § I.—Indications.

  A. Compression, employed from 1809 to 1816 by Yonge, rejected
as dangerous in 1817 by the physicians of Middlesex, upon the report
of Chas. Bell,  and proposed at a subsequent  period  by Pearson, has
since afforded to M. Recamier results which this practitioner considers
worthy of attracting attention in treatment of  tumors  of the breast.
Nevertheless this is not a reason for rejecting the operation properly
so called, or for not recurring to it but as an extreme measure as some
people seem to think. Many women cannot support compression, how-
ever well it may be made.  A great number of cases obstinately re-
sist its  application, and nothing proves that it has  ever cured a true
cancer.  Under the most fortunate circumstances, the assiduous cares
that it  exacts  are so  fatiguing  in themselves,  as to have given rise
to the question, if extirpation  be not preferable to  it.   It is not, in
fact, as an  operation, that extirpation of the breast is dangerous, but
because  it  is frequently followed by a return.   The amount of pain
that it  produces is assuredly less  than that which results from  a
course  of treatment whose duration cannot be less than from two to
three months.  In an instant the patient is relieved of her disease,
and fifteen  days or a month ordinarily suffice  to effect a  complete
cure.   On the other hand there is no reason for maintaining that the
return would be less frequent  after the employment of the compress-
ing bandage, than after the ablation of the scirrhus.   Experience has
already shown that when it becomes necessary to suspend the com-
pression, before having entirely dispersed the morbid mass, the pro-
gress of the cancer soon goes on with an increased rapidity, in such
manner that its development,  though momentarily arrested, soon as-
sumes a more  frightful character than  ever.
  B. As to the  question whether extirpation  is  a remedy which
sound practice ought to allow us to *nake trial of, I do not hesitate to
answer in  the affirmative.  To Celsus,  (Sprengel, t. VIII., trad.
Franc, p. 422 ; Celsus, liv. V., chap, xviii., sect. 2,) who forbids the
cancer  from  being meddled  with, because  it always returns ;  to
Albucasis, (Chir., lib.  II., s. 53 ;  Sprengel, VIII., 487,) whoJias never
seen the operation followed by entire success ;  to Monro, (Sprengel,
VIII., 457,) who says  that out of more than  sixty women whom he
had met with,  after this operation, four only had not had a return at
the expiration  of two  years;  to Boyer, also, (Mai. Chir., t. VII., p. 
TUMORS  AND EXTIRPATION OF  THE BREAST.
171
 237,) who, out of more than one hundred cases, could cite only a very
 small number of radical cures; to Rouzet, (Rech. et Obs. sur le Cancer,
 1829,) who asserts that  he has found  in the annals of science but
 very equivocal evidence of permanent success ; and to M. McFarlane,
 who, out of one hundred cases, has not seen one effectual cure ; we
 may oppose the  evidence of Hill, (Cases in Surgery, Edinburgh,
 1772,) who, out of eighty-eight extirpations, most of which were ulce-
 rated, has met with but twelve failures ; that of Schmucker, (Bibliot.
 Chir. du Nord, p. 296,) who operated at the beginning of the disease;
 that of B.  Bell, who confirms the accuracy of Dr. Hill; and that of
 Dr. North, quoted by Dorsey, (Elements of Surg., &c, vol. II., p. 4,)
 and who, out of  one  hundred  examples,  noticed but  a very small
 proportion of a  return of the disease.   MM. Richerand, Roux and
 Dupuytren, and  before them Sabatier, on their part,  had evidence
 that cancer is far from  repullulating always, when the  extirpation
 has been made in time.  My experience also shows that many pa-
 tients operated upon at Tours by M. Gouraud, at the  hospital  of St.
 Louis by M. J. Cloquet, and at the hospital of the School of Medicine
 by MM. Bougon and Roux or myself, since the last 12, 8, 6,4  and 2
 years, continue to enjoy good health.
   C. Cancer of the breast is not the external sign of a general disease,
 as Delpech maintains, at least in  most cases, except at quite an ad-
 vanced period of its development. In the  majority of cases, it is at
 first only a local affection, but one which tends constantly to  pervert
 the fluids and solids to such extent as to be soon reproduced on one
 region or another, although it may  have been entirely destroyed at
 the part where it appeared to be situated.
   Consequently nothing can be more  dangerous than to shrink from
 its ablation under idle pretexts ; and compression, which is necessa-
 rily less efficacious, would not be proper to be had recourse to, except
 in timid persons, or such as from any  cause whatever  were not wil-
 ling to submit to the action of the bistoury.  If general and local treat-
 ment possess  any value, the operation, which is in no respect incom-
 patible with their employment, cannot but favor their success.   We
 should be wrong even to allow ourselves to be deceived' by the pres-
 ence of certain glands at the hollow of the axilla or in the supra-clavi-
 cular region.  "These glands may have preceded the scirrhus, or been
 produced by it without participating in its character. Bartholin, Bor-
 rich, Assalini and  Desault,  (Sprengel,  Hist, de la Med., t. VIII., pp.
439, 440,) have seen them disappear spontaneously after extirpation
of the cancerous breast.  The same fact has been frequently noticed
in these  latter times.   This result took  place in 1825, in a woman
operated upon by M. Roux, at the Hospital of Perfectionnement, and
who had a chaplet of indurated glands extending from the side of the
neck down into the hollow of the axilla.  Nor does a slight yellowish
tint, or the commencement  of what is  called the cancerous diathesis,
always form  an  absolute counter-indication.  Morgagni, having to
treat a patient in this condition,  ventured to extirpate in  spite of  the
formal advice of Valsalva.   The cancer returned at the  end of five
years; Morgagni  again operated  and the disease  was not repro-
duced.  The adhesions of the tumor to  the ribs considerably dimin-
ish the  chances  of success, but do  not render it absolutely impossi- 
172
NEW ELEMENTS OF OPERATIVE  SURGERY.
ble.   The operation therefore should be performed in all cases where
the last roots of the disease may be extirpated without occasioning
too great a loss of substance, and where there is no evidence to show
that it exists in the other organs.

                   §  II.—Operative Processes.

  It is to the barbarous processes used at different epochs by various
surgeons, that  we must look for an explanation, if the removal of the
breast still occasions so much alarm to people in general.
  A.  Cauterization of the wound with the iron heated to a moderate
red heat, already mentioned in the writings of Galen ; the  precept
of Leonidas, (Aetius, tetr. 4, serm. 4, cap. 43; Sprengel, 8, 423,) to
burn after each cut of the bistoury the bottom of the wound in order
to prevent hemorrhage ; or excision with the knife heated to  a white
heat, or when  the cancer is adherent, by means of a blade of horn
which has been dipped in aqua fortis, as prescribed by J. Fabricius,
(Op. Chir., p.  1, cap. 49; Op.,  196;  Sprengel,  8, 436,) must necessa-
rily have been attended with excruciating pain.  The process of Scul-
tetus, (Armam., p. I., p.  22, tab. 24, 36 ; Sprengel, 8, 441,) which con-
sisted in introducing two threads crosswise through the tumor, in order
to raise it up and excise it with a single cut of a large concave bis-
toury, and then to cauterize the  entire bleeding surface with a plate
of red hot iron ; that of Purmann, (Chir. &c, t. II., chap. 6,  p. 144;
Sprengel, 8, 444,) who added  to these  threads a ligature strongly
tightened upon  the  root of the disease with the view of benumbing
the  parts; those  of Nuck, (Obs. et Exper. Chir., p.  101;  Spren-
gel, 8, 445,)  who used a double hook and a falciform knife ; of Dio-
nis, (Oper.  de  Chir.,  demonst.  XL, fig. 28,)  who commenced by
plunging into the  cancerous mass those famous Helvetian forceps of
which so much was said at the commencement of the last century ;
of Hartmann,  (Barbeu, These de Holler, t. I.,)  and Vylhorne, (De
Cancro. Mam., &c. ; Haller, 2, 449 ; Sprengel, 8, 453,)  who after
having strangulated the schirrus at its base,  secured it still farther by
means of a  sort of veterinary pincers, (moraille,) and then with the
bident of Helvetius, while its excision was  effected by a mechanical
instrument  of  their invention ; and of Schmucker, (Chir., &c, lib.
II., p. 51 ; Sprengel, 8, 471,)  who after having laid open the skin
pressed the tumor in order to make it protrude, introduced into it a
species  of awl slightly curved, and then separated  it from the sur-
rounding parts;  were also well calculated  to create such appre-
hensions.
  B.  Those who  caused the separation of the tumor by surrounding
it with a ligature saturated with aqua fortis, or who having entirely
or partially excised it  in  one  way  or another, made use of the re-
peated applications of arsenic, orpiment, potash, butter of antimony,
&c. ; and those who cautiously dissected all the surrounding vessels,
in order to place  a double ligature on each of them, and to divide
them without danger in the interspace of the two threads before re-
moving the cancer, or who after  the  incision of the integuments
made use only of their fingers, and terminated the operation  by tear- 
            TUMORS AND EXTIRPATION  OF THE BREAST.         173

ing out the tumor, presented no arguments for changing public opin-
ion upon this subject.
  C. At the present day, when extirpation of the breast is reduced
to its greatest simplicity, there is nothing in it which is alarming or
in reality severe.
  I. When the skin is in  no respect  diseased,  nor the tumor of a
large size or adherent, the surgeon confines  himself to dividing the
common integuments, taking care to give to  the incision  all the ex-
tent required, and to cause  its lips to be separated apart,  while with
an erigne, or even with the ends of his fingers, he draws the scirrhus
to the  exterior,  and with  the  other hand armed with a bistoury,
destroys all its cellular or vascular attachments.  When  the patient
possesses a certain degree of embonpoint, or that the breasts are na-
turally greatly developed, though the carcinoma may be clearly cir-
cumscribed and preserve all its mobility,  there is some advantage in
not being so sparing of the  skin, and in excising even an ellipse from
it of greater or lesser  extent.   The operation is  thus rendered more
easy and more prompt.  Its success also then becomes more proba-
ble, for the lips of the wound, which are then moreover cut almost in
a uniform manner, are placed under more favorable conditions  for
exact coaptation, than if all  the integuments had  been preserved.
   II. If the skin itself is  comprised in  the disorganization, or red,
or  too  attenuated ever to acquire its primitive  characters; or if it
adheres by its deep-seated  surface to the morbid mass, we are still
compelled to adopt the same  precept, and to include the entire dis-
eased portion between two incisions, which should  always embrace
a certain extent  of sound  parts, that  is,  between two semilunar in-
cisions,  as recommended by  Zeller and Kern, (Rust. Handb.de Chir.,
vol. VI.)  In conclusion, it is much better to remove more than less,
provided we leave enough to allow of reunion of the wound by first
intention.  The  circular incision adopted by the ancients, and also
by Dionis, is  essentially objectionable.   It makes a wound which is
difficult of cicatrization, and the loss of substance which it produces
is much  more considerable  than by any  other mode.  It  can be ap-
plicable only to globular tumors, which are as it were confounded with
the skin upon their anterior surface.  It would be under such circum-
stances,  that we might, after the example of M. Fardeau,  (Journ.
Hebd., 1835, t. IV.,  p. 110.)  by means of a knife introduced through
the tissues between  them and the  chest, detach the tumor  first above
and then below.  The elliptical incision which was already used by
Paul of Egina, (Sprengel, t.  VIII., p. 425,) and afterwards by Chesel-
den, (Observ., &c, 1749; Sprengel, t. VIII., p. 452,) &c,  is the most
convenient of  all.   The crucial incision preferred by Palfin (Spren-
gel, t. VIII., p. 450,) and Heister,  (Institut. Chir., Sprengel, t.  VIII.,
p. 451 ;) and the T incision employed by Acrel, and even by Cho-
part, (Sprengel, t. VIII., p.  475,)  evidently possesses fewer advan-
tages, and would be applicable only in certain particular cases.
  D.  Some with Gahrliep and M. C. Bell, place  the great  diameter
of this incision from above downwards;  others prefer that it should
be transverse; while the precept  of Pimpernelle, recommended  ac-
cording to Sprengel by Verduc, and which consists in placing it ob-
liquely from above  downwards, and from without inwards;  that is 
 174          NEW ELEMENTS  OF OPERATIVE  SURGERY.

 to say, in the direction of the fibres of the pectoralis major, is gene-
 rally adopted by the moderns.   The advantage of being enabled to
"apply the uniting means with more  facility in the first case, is more
 than*counterbalanced by the risk of dividing the muscular fibres per-
 pendicularly, and of not being enabled to bring to the outside the ster-
 nal portion of the integuments but with much difficulty.  The second
 process  would incur  the  risk  of the same  inconveniences, without
 which enables us to employ the adhesive straps, as well as any other
 presenting the same advantages.  Consequently the oblique incision,
 process,  and which leaves intact the fibres  of the pectoralis major,
 deserves the preference which is now accorded to it.
   E. In  a case of  necessity, all cutting instruments are applicable to
 this operation.   We could, if  so disposed, succeed with a  razor  or
 amputating knife.   The bistoury, with a broad  and  square-shaped
 point, devised  by A. Dubois with a view of avoiding the chest with
 greater certainty, is neither better nor worse than any other.  The
 ordinary straight bistoury, or better  still the convex, is the one which
 is usually employed.   In  order that the blood of the first incision
 may not  interfere with the execution of the second, we begin in con-
 formity with the indication laid down  by Palfin, and  afterwards by
 Desault,  by the lowest.   Nevertheless, when the section of the in-
 teguments has  been once effected, there is some advantage in dis-
 secting the tumor from above downwards.  In the opposite  direction
 the  lower or outer border of  the pectoralis  major would  be  much
 more exposed  to  the action of the  bistoury. No one moreover at
 the  present day recommends   with  Home,  (Sprengel, Hist,  de  la
 Med., t.  VIII.,  p. 440,) Lapeyronie.  (Ibid., 463,) and Le Dran, (Ope-
 rations, p. 375,) that we should commence by a  semilunar incision,
 and not complete the ellipse which is to represent the wound until
 after having detached the  cancer always in  the same direction, or,
 terminate by dividing the  skin  from the deep-seated  parts  towards
 the exterior, as recommended by M. Galenzowski.  This manner of
 proceeding however has no other defect than that of giving less reg-
 ularity to the termination of the operation, and of incurring the risk
 of destroying too great or too small an extent of the cutaneous tissue.
   F. When the loss of substance is considerable, and  to so great an
 extent as to render the coaptation of the borders  of the division im-
 possible,  or at least very difficult,  it has been  proposed  to  isolate
 each lip  of the wound from the subjacent parts, to the distance of
 one or several  inches, hoping  by that means to  remove all the ob-
 stacles which are opposed to their approximation.  This is a  modi-
 fication,  the value  of which, in my opinion, has not hitherto been
 fully appreciated.   By means of this process we should always have
 a sufficiency of skin to unite the wound by first intention ;  the integu-
 ments are then  borrowed from the surrounding  parts, and the pro-
 cess must always  be  a precious resource in cases where we have
 been compelled to  destroy a large portion of the cutaneous envelope.
 Under the chapter on anaplasty, I have  stated what value  ought  to
 be placed under such circumstances upon the different descriptions
 of autoplasty, and especially of the process that  M. Martinet (Gaz.
 Med., 1834, p.  657) appears to  have employed.
   G. Th° small arteries  that are  divided belong to the external 
TUMORS AND EXTIRPATION OF THE BREAST.         175
mammary, the superior thoracic, the internal mammary or the inter-
costal arteries.   Those  that we meet of the largest size, and which
we must first attend to,  are always towards the outside.   In placing
a ligature upon  them in proportion as we divide them, there is no
danger  that  they will retract and escape into the midst of the tis-
sues, nor  that the action of the air will  prevent our finding them
again subsequently;  but the operation in this way becomes  more la-
borious and protracted.  Unless they should be too numerous or very
large, I prefer making use of the fingers of an assistant to close their
orifices at the moment that they are divided hy the bistoury.  Should
there be any  which cannot be found after having cleansed the wound,
they are generally too small to occasion the slightest inquietude.   In
the contrary  case, it would be so easy to establish upon them a point
for indirect or direct compression, that in this respect we have in
reality but little to apprehend.  Even when we unite by first inten-
tion, ligatures are far from being always indispensable.   Theden did
not make  use of them;  and Petit ordinarily dispensed with them.
D'Arce and  Vanhorne, who also omitted  them,  tore out the tumor
with the fingers, and only used the bistoury for  dividing the integu-
ments.  I  have  frequently dispensed with them, and among other
cases, in that of a young woman in whom  I had removed a scirrhous
mass as large  as the  fist.  Prudence, however,  requires  that we
should tie or  twist all those which may be recognized; and that if
there be any that escape the researches of the surgeon, the dressing
should be carefully  watched during the space of a day or two.
   H. The precaution of not definitively  dressing the  wound until
after the expiration  of some hours, in order to give time for the  cen-
trifugal action of the vascular system to become established, and to
make manifest the arterial mouths which are  to be closed, would  pos-
sess the serious inconvenience of worrying and tormenting many
patients, and  of  being at the least unnecessary.   At the present day
it would be absurd and  barbarous to dissect, as  has been recom-
mended, and  afterwards to excise all the veins that go to the#.,breast,
or only to compress or agglomerate (masser) them by means«of the
fingers, in order to extract or expel from them that black or atrabil-
iary humor which the ancients had so much  dread of.
   I. Immediate  union, which was indicated by  Paul and Gahrliep,
and lauded by Nannoni, who confined himself to approximating the
lips of the wound, and also by Cheselden and Garengeot, who  em-
ploy the suture,  and which has been  adopted by almost all  the mod-
erns, nevertheless finds  some  opponents.  The objection made  to it
is  that it interferes with  the issue of any  matters  that  may form at
the bottom of the  wound,  and  of  being frequently  followed by
phlegmonous erysipelas, and consequently that it may jeopardize the
success of the operation.  These formidable accidents, especially in
fat or cachectic women, will be in most cases  avoided, if no void is
left at the bottom of the wound, if the coaptation is more exact  near
the muscles than towards the skin, and if the  containing means act
principally upon the deep-seated parts, and not exclusively upon the
cutaneous  tissue; if in a word we take care to  reserve an  opening
at a depending part for the escape of the fluids.  Moreover, as  it is
almost next to impossible to obtain perfect primitive reunion, perhaps 
176
NEW ELEMENTS  OF OPERATIVE SURGERY.
it would be more  prudent  to treat the wound by secondary imme-
diate union.  As to the suture,  though again warmly recommended
by M.  Serre, I should not venture to recommend  its employment in
these cases, until after having seen results from it more fortunate or
more conclusive than those which it  has given me up to the present
time.   It evidently renders  the  operation more painful.   Except in
certain  cases, where the  skin is so attenuated  that after  being dis-
sected  it has a tendencv to  roll  up upon itself, adhesive  plasters, or
the simple bandage, may be perfectly well  substituted  for  it.  M.
Chaumet, (Journ.  des Conn. Med.-Chir., t. V., p. 117,)  who gives
three examples of  it and  eulogizes it, says that the cure  in his  first
patient was effected in 52 days,  in 15 days in the second,  and in one
month  in  the third; but  since  without its employment we may, in
reality,  accomplish the cure in  the space of ten to twenty days, I
cannot see what advantages it would possess.

                    § III.—Operative Process.

  Though we may, as many practitioners do, support the  patient on
a chair while we are operating  upon  her, there are nevertheless in-
disputable advantages in  placing her in a recumbent posture, either
upon the  bed or upon an operating table.   The syncopes are  then
much less to be apprehended, and the surgeon is in fact much more
at his ease.  The  head and chest  are to be sufficiently elevated, to
make the  breast project as much as possible.  The pelote which Bid-
loo directed to be placed in  the axilla, in order to push the  breast for-
ward while the arm was directed backwards, would not  deserve to
be mentioned, if M.  S. Cooper  had not  recommended a precaution
which is somewhat analogous and not less curious: he advises  that,
in order to keep the arm separated from the trunk, to command the
movements of the  patient, and to force the pectoralis major to be-
come stretched, a baton should be fixed upon each side in the hollow
of the«axilla, between the chest  and the limb !
  A.*A second assistant raises up the tumor with one hand, and with
the other  sponges  up the blood in proportion  as it runs  out.  The
surgeon makes traction upon the skin  in an opposite direction; com-
mences with the lower semilunar incision ; then depresses the mass
to be removed and stretches the integuments above;  applies the bis-
toury to the outer  angle of the  first wound; and makes  the upper
incision by conducting it to the other extremity of the lower division,
and in this manner completes his ellipse.  He then seizes the scirrhus
or causes  it to be grasped, dissects it freely, first from below upwards
and then from above downwards ; proceeds in such manner that the
tumor may continue surrounded by  a margin of sound tissues and
not be elevated exclusively; cuts down to, or ought not to fear cut-
ting down to, the muscular  fibres, and even as far as to the  ribs of
the  thorax, should  the  extent of the disease require it.
  B. If, as I  prefer,  unless  there should be large arteries that  they
should  not be tied, the surgeon directs them to  be closed with the
finger in  proportion as the bistoury divides them, and may in this
manner terminate in a few seconds  the  ablation of a breast of the
largest volume.  Upon the  supposition that some morbid layers or 
TUMORS AND EXTIRPATION  OF THE BREAST.
177
peletons have at first escaped the instrument, we must afterwards re-
turn to them without delay.  When they belong to the soft parts,
they are to be excised by the bistoury or the scissors, and should the
bones be affected, the rasp might become necessary.  Having arrived
at this point we should not  even  hesitate to exsect one or more  por-
tions of the ribs, should  it  appear that their removal would enable
us to destroy all the parts diseased;  but if before commencing, this
change had been indicated by any sign, it would in my opinion be
much better not to undertake the operation.
   C. If there should be found in the arm-pit, glands which create
some apprehension, they are when not too remote to be laid bare by
prolonging over them the external angle of the  wound.  In the con-
trary case it  is better to  cut down to them by means of incisions in-
dependent of the first.  Their position, which is calculated to  pro-
duce some alarm at first view, nevertheless allows of their being ex-
tirpated in almost  every case without the slightest danger.  They
are in  fact almost always constantly found upon the outer surface of
the serratus magnus, so that in order to separate the brachial plexus
from them, we have only to raise up the arm and to hold it at a slight
distance from the trunk.  Nothing moreover is  easier, when we are
under  an apprehension of wounding any vessels of considerable  size,
than to embrace  their pedicle with a ligature  after  having isolated
them in  a proper  manner, and  then to excise them  external to the
thread.  This practice, which had already been recommended by J.
L. Petit and Desault, and which Zang and Dupuytren adopt,  deserves
to be retained.   As to the division of the veins it is rarely alarming
in respect to hemorrhage.   I have  seen  the axillary vein itself
wounded during an operation of this  kind, and tamponing suffice for
the effectual arrestation of the effusion of blood.
   D. If, after having cleansed the wound and the surrounding parts,
the operator is  desirous of  attempting immediate reunion, he gently
approximates the  borders of the division and keeps them in contact
by means  of the thumb and forefinger of each hand, while the assist-
ant applies the adhesive plasters.  In general, the longer the adhesive
plasters are, the better.   Being stretched over a great extent of  sur-
face, their action becomes much less  irksome at the cutaneous divis-
ion, while  they are kept on  infinitely  better than if they were short
and more numerous.   Some persons, however, allege the contrary,
and Prof.  A. H.  Stevens of New York, among them, recommends
that they should be as short as possible.  It is necessary that they
should  cross the wound at a  right angle.   When the loss of substance
is considerable, or that it  becomes difficult to bring the integuments
into coaptation, there is an  advantage in attaching them behind the
sound shoulder and then bringing them above the clavicle and con-
ducting them to bilow the axilla or  upon the  diseased side.   We
begin  with those of the  middle and  finish with those at either end.
Their number should  vary according to the extent of the wound, in
front of which they are to form a kind of grillage sufficiently close.
A plumasseau besmeared with cerate, and one or two gateaux of dried
.int with long compresses, supported  by a  body bandage or the cir-
culars of a long band, passed moreover once or twice in the form
  vol.  iil                       23 
 178           NEW ELEMENTS  OF OPERATIVE SURGERY.

 of a quadriga around the shoulders, complete the dressing, when the
 patient is immediately removed to his bed.
   E.  When we cannot, or do not wish to attempt immediate reunion,
 adhesive plasters are generally of no use.   We then surround the
 wound with bands of linen besmeared with cerate, or we cover it
 with  a fine linen uniformly imbued with ointment and perforated, in
 order that the lint which is to be  placed over this may be easily
 removed at the first dressing.  If afterwards there should appear the
 slightest vegetation or  tubercle of  doubtful character,  it should be
 destroyed without  hesitation and as quickly as possible, either by the
 cutting instrument, the red hot iron,  zinc paste, or any other caustic,
 such,  for example,  as those recommended by La Poterie, F. Come,
 A. Dubois, &e.  I will  add no remark  in this place to what I have
 already said of caustics in the chapter which  is devoted to them in
 this work and under the article on tumors.  The cancers which pre-
 sent,  in this respect,  the least hope of success, belong especially to
 the cerebriform, melanotic and scirrhous  tissues.  Those which seem
 to be, and are in fact, prolonged into the surrounding cellular tissue,
 by a number of divergent radii or roots,  are the most formidable of
 all, and rarely fail to be reproduced ;  while on the contrary, the extir-
 pation of colloid cancers, and hydatiform, encysted and tuberculous
 tumors, is quite often  followed by a  radical cure.
   F.  If the case is that of a man, as in the examples related by Bar-
tholin and MM. Sedillot and Petrequin, and in those which belong to
myself, the operation should be nevertheless performed after the same
 rules.  But in cases of cysts, whether milky, like those mentioned by
 Volpi, (Nelaton, These,  1839, p. 48,)  M. Cumin, (Trans.  Med. Chir.
■of Edinburgh, p.  594,) &c, or sanguineous,  or  sanguinolent, or
 serous, purulent, or hydatid, or osseous and mucilaginous, like those
which I have elsewhere described,  it would be better, unless there
should be  a considerable number of them,  to treat them with injec-
 tions of iodine or by incision, and even simple excision, than to attempt
 their extirpation.   I have only to refer, moreover, for what relates to
the different kinds  of tumors of the breast, to what I have said of the
processes that are applicable to tumors in general, and also to my spe-
 cial memoir (Traite des Mai. du Sein., Paris, 1838,) upon this subject

  Article  II.—Tumors cf the Thorax disconnected  with the
                            Mamma.

   The cases,  first  of a hypertrophied mamma weighing sixty-four
 pounds, observed by Durston,  (Nelaton,  These de Cone, 1839, p. 5,)
 another which weighed twenty  pounds  as mentioned  by M. Ko-
 ber,  (Ibid., p. 7,) the three examples of gynecomasty,   noticed  in
 man by M. Bedor, (Ibid., p. 17,) those of osseous tumors described
 by Morgagni, Bidloo, Wolf and Cooper,  of tuberculous masses extir-
 pated by M. Gerdy, (Ibid.,  pp. 45—47,) of milky calculi encountered
 in animals  by Ruysch  and Morgagni,  and in man or woman by
 Rufus, Bassius, Kulm, Morgagni,  Dupuytren, (Ibid., p. 59,) &,<;., will
 have  to be added  to those which I myself have  related.   A  vast
 erectile  tumor, which occupied the  side of the chest and the hollow
 of the axilla, was extirpated with success by Marechal, (Arch. Gen. 
EMPYEMA.
179
de Med., t. XXVIII., p. 149.)   Having treated in detail, in the chap-
ter on loupes  and other  tumors, of tumors  upon the thorax and in
the axilla,  it is unnecessary for me to recur  to this  subject in this
place.
                        CHAPTER  II.

                EFFUSIONS INTO THE  THORAX.

                     Article I.—Empyema.

                        § I.—Indications.

   The operation of empyema, performed in the remotest period of
antiquity, owes its origin, according to  fable, to the despair of Phales
or Jason, who, seeking death in the midst of battle, received the thrust
of a lance in the  chest, and was thus relieved of an empyema, of
which no person had ventured to undertake the cure.  Galen alleges
that in Greece it was performed  by plunging  a red hot iron through
the thorax.   At the time of Hippocrates, after having satisfactorily
ascertained the existence of a collection, an opening was made into
one  of the lowest  intercostal spaces with the bistoury or a  large
lancet protected by linen wrapped around it.  Others, for fear of
evacuating all  the  liquid too rapidly,  perforated  the fourth rib by
means of a trephine, and then closed up the hole with a plug or tent.
   The Arabs appear to have proceeded in the same manner in this
respect as  the  Greeks and  Romans.   Among both it is perceived
that  the  operation for empyema* first recommended and employed
without repugnance by most practitioners, ended in being no longer
recommended by any person.  Paul of Egina, among the first  class,
recommends that it should be replaced by cauterization of the thorax,
and Haly Abbas, among the second class, formally rejects it.  G. de
Salicet and Guy de  Chauliac speak  of it with extreme dread.  A.
Benedetti, J.  de Vigo, and Pare did not succeed but in temporarily
rescuing it from the discredit into which it had fallen, and it required
all the efforts of J. Fabricius to bring it again into repute; so that it
is  only in reality during  the  last two  centuries that its advantages
and inconveniences have been discussed, and that it has  again at-
tracted the attention of surgeons.
  A.  Sanguineous Effusions.—Whether the  blood which has accu-
mulated  in the pleural cavities proceeds  from the  intercostal arte-
ries,  or from the deeply situated vessels, whether it proceeds  from a
traumatic lesion, a perforating wound,  or  a spontaneous  laceration,
or whether it be arterial or venous, the dangers nevertheless which
result from it, and  the remedies  to  be employed for its relief, are
nearly the same.   The advice that we should immediately proceed
to the extraction of the effused liquid, either  by placing the patient
on the wounded side, by enlarging the  wound, or  by making use of
the mouth, a cupping-glass, or a syringe, to  suck out the fluid as it 
180
NEW ELEMENTS OF OPERATIVE  SURGERY.
were with a pump, far from being advantageous, appears on  the
contrary to be extremely dangerous.  Is it not moreover probable,
that after the first hours, and until time shall have been given for the
blood to become again liquefied, it will be found in  part at least in the
condition of clots  in  the chest, and that in such cases it would be
impossible to extract  it by a puncture ?  The vessels wounded can-
not be obliterated or closed  up except  by means of clots  more or
less  solid, and a  greater or less degree  of  strong  compression.  If
in place of being retained in the chest, the blood escapes to the out-
side by this compression, the clots will not be made to  form and the
hemorrhage will end only in  death.   Reason therefore instructs us
to close up the wounds of the chest immediately at first, in place of
dilating them, and to imprison the extravasated blood in the  interior
instead of procuring an exit for it.  If the  effusion is inconsiderable,
it will generally  be removed by absorption; in the contrary case, its
source cannot be surpressed but by itself and by the mechanical re-
action which it soon exercises against the  wounded organs; so that
the operation for empyema is  under no circumstances proper  for
recent traumatic hemorrhages of the thorax.  Some facts collected
in the time of Vigo and Pare, a passage in Francois d'Arce, another
in G. Horst, and the remarks of Sharp, and especially of Valentin,
would  have naturally led  to  this suggestion ;  but it was reserved
for A. Petit and  M. Larrey to have the honor of demonstrating and
satisfactorily  establishing, that the  first  indication  in perforating
(penetrantes) wounds of the chest, whether with or without effusion,
is to close them up immediately.   If afterwards the system, aided by
judicious general treatment, should be found incapable of effecting
the dispersion of the morbid collection; or if when  the  wounded
vessels have had time to become obliterated, this collection threatens
in itself to give rise to serious accidents, it is then allowable, but only
under such circumstances, to have recourse to the operation, and to
perform what is  denominated a counter opening.   The memoir of
M. Priou, on wounds of the  chest, (Mem. de VAcad. Roy. de Med.,
t. I.,) will give the reader every information necessary on the sub-
ject of effusions of blood in the thorax.
  B. Effusions of Pus.—As purulent collections  in the chest are far
from constituting always the principal disease, the operation for em-
pyema in such cases, in its turn,  is far from being always a source
of" any great benefit.   If they have originated from a tuberculous
vomica, or  any other incurable lesion of  the  pulmonary organ ; if
they are the product of a deep-seated alteration still existing in  the
heart or pleural linings, we  should,  by giving  exit to them, only
hasten the death of the patient.  If, on the contrary, they have been
caused  by a  simple phlegmasia, or pleurisy for  example, or by an
abscess in the lung which has made its way into the pleural cavity,
the operation  presents some chances of success and  ought to be
made trial  of.   A vomica opened into  the pleural cavity and ulti-
mately presented itself at the left  hypochondrium.  The pus which
flowed out from  this part in abundance, was also  ejected through the
bronchi.  When the  patient vomited the wound  in the side closed
up;  but when, on the contrary, the pus issued at  the hypochondrium
the vomiting was arrested, and this condition of things did not ter- 
EMPYEMA.
181
minate until after the expiration of fifteen months.   I have met with
two other cases of this description, and MM. Jaymes,  (Journ. Gin.
de Med., t. 48,) Roc, Wioley, and Davies (Revue Med., 1836, t. II.,
p. 260,) have mentioned other  similar ones.  A peasant in the envi-
rons of Tours, operated upon in 1814 by M. Gouraud, was perfectly
restored.  Freteau, (Journ. Gin. de Med., t. XLVI1., p. 121,) Ollen-
roth, (Diet, de Med., 2d edit., t. II., p. 431,) and Audouard (De VEm-
pyeme, &c, 1808,) were no less fortunate.  In the cases under con-
sideration the effusion approximates in its character to external  ab-
scesses.   The organism, in most  cases, has adopted the precaution
of surrounding it with adhesions,  which more or less accurately cir-
cumscribe its limits; from whence it  happens that after an opening
has  been made, the  remainder of the pleura has nothing to appre-
hend from the contact of the air.   In proportion as it is evacuated
its walls may collapse  upon themselves, and soon completely close
up the void.  The same remark, moreover, is applicable to sanguine-
ous effusions, which almost always also ultimately become contracted
to more or less circumscribed dimensions, under  the influence of  the
adhesive inflammation of the surrounding surfaces.
   C.  Effusions of serosijy.—Serous  effusions  do  not present  the
same chances of success.  The surfaces which supply them  are  not
sufficiently irritated, at  least in general, to contract adhesions with
each other.   The lung gently pushed  back towards its root, and soon
deprived of all permeability, is then incapable of resuming its natural
dimensions,  and the chest being  once  opened  into, may place  the
whole extent of the pleura  in contact with the air;  so that  many
surgeons, in such cases, reject even  the very idea of the operation.
Nevertheless if all  the  means that reason  or experience point out
have  been tried in vain, if it be  not  positively ascertained  that an
incurable organic lesion is the cause of the effusion, and if the alarm-
ing symptoms  and suffocation  threaten the life of the patient, the
operation of empyema is  a last resource, which it would be unjusti-
fiable not to perform.  M. Gouraud effected .a remarkable cure by
it in 1808.   We owe one also to M. Tuson, (Lond. Med. Gaz., June,
1837, p. 396,) who, in this manner, extracted  nine pints of liquid from
the thorax after  a  pleurisy.   M.  Caffort (Private Letter, October,
1837,) informs me that he has succeeded in four cases out of six; and
scientific collections in various places, contain other examples, which
I shall shortly speak of.   The artificial subtraction of a portion of
the effused  liquid, so actively promotes absorption in the pectoral
cavity, that  several practitioners have considered that the operation
of empyema should be laid down  as a rule after  pleurisies whose re-
solution can be no longer hoped for.  It  must be confessed, however,
that it rarely succeeds under such circumstances.   The patient men-
tioned  by M. Martin Solon, (Journ. Hebd., 1830, t. II.,) who  de-
clares himself its advocate, perished.   The same was the case in the
patient operated upon in 1830 at La Charite,and with the one whose
thorax was opened into at the hospital of St. Antoine. while I was in
service there.
  D. Effusions of Gas.—The presence of air or gas in the interior
of the pleural cavities, which so many physicians have noticed since
Itard  made  it the subject of an  interesting memoir, whether it be 
182
NEW ELEMENTS OF OPERATIVE  SURGERY.
 caused by the  laceration of a pulmonary cell, the decomposition  of
 certain liquids or by a pure and simple exhalation, is also one of those
 cases w^ich might possibly require the perforation of the thorax.
 Riolan  and H.  Bass have  had evidence of this  in  patients in whom
 the chest, instead of the pus they expected to find there, contained in
 reality nothing but air.  The researches of A. Monro and Gooch,
 and especially  of Hewson, leave not the slightest doubt upon this
 subject.   Nevertheless it  is not  to be forgotten that under such cir-
 cumstances it is a symptom of but trivial importance in itself, that
 may disappear spontaneously, and that if it is accompanied with a
 deep-seated organic alteration, the operation of empyema will afford
 but temporary  relief.
                      § II.—Appreciation.
   The  successful results obtained from the operation for empyema,
 moreover, are  very numerous at  the  present day.   Besides  those
 above,  Baillou, (Bonet, Corps de Aled., t. IV.,  p. 558.) who made
 his incision between the fifth and sixth ribs, also mentions one; Mar-
 chettis  (Ibid., t. III.,  p. 247) mentions  two;  and Rey, who left  a
 canula in  the wound, two otners.   We are indebted  also for two  to
 M. Martini (Bull,  de  Fir., t. VII.,  p. 162;) for one to M. Norfini
 (Ibid., t.  XVII., p. 648;)  three  to  M.  Herpin (Precis d'Indre  et
 Loire—Gaz. Med., 1833, p. 417;) three to M. Reybard, (Arch. Gen.
 de Med.,  t. XVII., p. 648,) and  two to MM. Tourdes  and Malle,
 (Bull, de  VAcad. Roy. de Med., t. I., p. 402.)  Out of six cases, M.
 Rey (Arch. Gen. de Med.,  2d  ser., t. XII., p.  338) counts four cures;
 M. Dieffenbach (Gaz.  Med. Chir., t.  II., p. 56) has cured three out
 of four; M. Roque (Bull, de VAcad. Roy. de Mid., t. I., p. 457) three
 out of five, and M. Davies (Encyclogr. Med., p. 49) eight out of ten
 cases.   M. Faure, (Bull, de VAcad., 1.1., p. 62,) however, has obtained
 only one or two cures out of eight  cases, and though  MM. Roux,
 (Ibid., pp. 65, 101,)  Bricheteau, (Ibid., p. 124,) Brigham, (Gaz Mid.,
 1833, p. 324,) Larrey, (Bull, de VAcad.  Roy. de Med., t. I., p. 160,)
 and Caffort (Private Letter, October, 1837) have each in their turn
 seen it succeed, and that M. Guerard, (Arch. Gin. de Med., t. XIII.,  p.
 270,) performing it twice on the same subject at an interval of forty
 years, has been no less fortunate ;  though in spite of a syphilis  and
 carious  rib, another patient (Gaz.  Mid., 1833, p. 418) has  also been
 restored by  it, and that  M. Reybard  has  cured almost all those
 whom he  has operated upon,—this operation, nevertheless, has  been
 unattended with success in an infinity of other cases.  Performed by
 M. Begin (Elem. de Chir., 2d edit., t.  II., p.  37)  on four different
 patients, two of whom  were attacked with effusions of serum, one with
 a sero-sanguineous  collection caused by hemorrhagic inflammation,
 and the  fourth with effusion of pus, it did not prevent all the four from
 terminating in a fatal  issue after having undergone numerous punc-
tures.   I have performed it or seen it performed twelve times my-
self, in the hospitals of Paris, and every one of the patients died.
 The dangers that it involves moreover may be readily conceived.  If
the lung, after having  been a long time compressed,  has not lost its
natural  permeability, the air is inhaled into  it with force, and may
thus become the source of an irritation or violent inflammation imme- 
EMPYEMA.
183
 diately after  the  abstraction  of the  liquid.   Upon the  supposition
 that  this organ has  shrunk so much as to yield  but slowly to the
 mechanical action of the  atmosphere, the species of void which is
 immediately left about the parts, which  up to that  time had been
 steadily supported, necessarily disturbs  the  pectoral circulation and
 the respiration.   The air without being irritating  or injurious  in
 itself, nevertheless, most usually exercises a pernicious influence upon
 the subsequent symptoms of the disease.   Being introduced into the
 chest it becomes heated and combines as it  decomposes with  the
 remains of the effused matter, which speedily  acquires  acrid and
 putrid  properties  which it did not possess before, and the action of
 which  is not sustained by  the system without danger.   It is this new
 material, not  the  air, properly so called, which  inflames the cavity
 and  produces a  general reaction, which  is sometimes exceedingly
 intense and too often  fatal; it is this  also which,  penetrating  in
 greater or less proportion into the  mass of the circulating fluids,
 infects them and gives rise to adynamic phenomena, to which a great
 number of the  unfortunate persons thus treated fall  a prey.  The
 danger therefore would be in proportion  to the extent of the walls
 of the collection, the  degree of  exhaustion, the irritability, force, and
 vital resistance of the patient, as well as in relation with the charac-
 ter of the matters effused, and with the conditions of the organs con-
 tained in the chest.

               § III.—Examination  of  the  Methods.

   Three points especially in  the operation of empyema require the
 attention of the surgeon ;  1st, the part of the chest at which it is to
 be performed; 2d, the most suitable  instrument for performing it •
 and 3d, the kind of dressing which becomes necessary.
   A. Place of Election and  Place of Necessity.—When the effu-
 sion  is  not circumscribed by any adhesion, and when the pleural
 linings are entirely free, it  is recommended to open into the pectoral
 cavity at the  part which is the  most  depending and most favorable
 for the egress of the  liquids, and this point is denominated the place
 of election;  when on the contrary,  the  collection is situated only
 in one region of the  chest, and that  it is  so exactly  circumscribed
 that neither the position nor the movements of the patient  can cause
 it  to change' its locality, the opening  should be made in a determi-
 nate  point, and this is what is termed the place  of necessity.  This
 latter has never varied, nor can it vary at the pleasure of practitioners.
 The other, on the contrary, being an affair of choice, necessarily
 cannot be nor has  it been in fact the same with  all surgeons.  Some,
 for example, with F. Walther, have placed it in the fourth intercostal
space, counting  from above downward;  others, with  Leonidas and
F. ab Aquapendente, in the fifth; and others, with Sharp, B. Bell, &c,
in  the sixth.  Heers recommends  that it should be in the seventh.
There are  those who,  like G. de Salicet and  Lanfranc, prefer the
eighth; others, with A. Pare", the ninth.   Solingen  thinks that it is
 better to select the tenth, as recommended by A. Lusitanus, for the
 left side, and the ninth for the  right; finally, Vesalius and Warner
 consider that it is  the eleventh  which offers the most advantages. 
184
NEW ELEMENTS OF OPERATIVE  SURGERY.
   1. In our times we generally prefer, at least in France, the third
 intercostal space for the left side and the fourth for the right.  Lower
 down we might wound the diaphragm or liver, or we might run the
 risk of passing the instrument  into the peritoneum and  strike below
 the collection; higher up we should miss the most depending  part,
 and the liquid would not flow with  all the facility desirable.  To
 these arguments  it is true it  might be  objected:  1.  That in large
 collections the diaphragm, and  the liver with it, is  too powerfully
 crowded  downwards to  be wounded even when we penetrate be-
 tween the second and third rib; 2. That we may change at pleasure
 the depending point of the thorax by giving this or that position to
 the patient, and that under this point of view the sixth or ninth in-
 tercostal space is nearly as advantageous as the third;  but as there
 is moreover no inconvenience  in  following  the precept adopted
 among  us, it would  be as advisable to conform to it as to seek for
 another;  so much the more so as the sensation of suffocation which
 usually  distresses those who are afflicted with effusions  in the chest,
 renders any other  position difficult for them than that  which more or
 less approximates to the vertical one.  Only that I do not consider that
 we should restrain ourselves too rigorously to perforate above the
 third rather than  the fourth rib, when  any difficulty should exist in
 distinguishing them.
  II. The intercostal space having been once decided upon, it remains
 to be determined upon what point of its length  the operation  should
 be  performed.  If very  near  the sternum, the  internal mammary
 artery might be wounded ; farther to the outside is found the descend-
 ing branch and anastomosing branches of this vessel.   In the direc-
 tion of the spine is situated the mass of the sacro-lumbar and  longis-
 simus dorsi muscles; a little  farther upon the side, the trunk  of the
 artery not being yet concealed  or protected by the lower border of
 the rib, might be  easily opened into.   It  is therefore with  reason
 that a choice has been made of the point at the union of the poste-
 rior third  with the two anterior thirds of the  contour  of the thorax.
 At that part the incision strikes  in front of the latissimus dorsi mus-
 cle, between  the  bundles or  digitations of the serratus magnus and
 obliquus externus  abdominis.  We have  nothing to divide but  the in-
 teguments, the intercostal muscles and the pleura.  The artery now
 lodged in the infra-costal  groove is not yet bifurcated, and the space is
 sufficiently large to admit the extremity of the finger.   Nevertheless
if this place should not offer moreover the very important advantage
of being the most depending when the patient is slightly inclined upon
 his side, or seated or lying down, there would be no inconvenience in
making  the opening  farther behind or in front, as David  and several
other practitioners have recommended.
  III. Many methods have been proposed to determine  with precision
the position of the third intercostal space.  If the patient is thin, all
that we have to do  is to count the ribs from below upwards ; but when
oedema or a thick layer of cellular or adipose tissue covers the ribs,
we are obliged to proceed in another manner. According to  some',
when the  hand of  the patient is placed over  the front part  of the
 sternum and the arm left pendent upon the  side of the trunk, the
 elbow when slightly pushed backwards, corresponds  exactly  to the 
EMPYEMA.
185
 space sought for.   This mode of exploration, besides being very in-
 exact, is much better calculated to conduct us  between the two last
 ribs than between the ninth  and  tenth;  and that  which consists in
 descending to six  fingers'  breadth below  the  lower angle of the
 scapula  in order to perforate the chest, would be infinitely more cer-
 tain and more rational if this locality had really the value which was
 formerly accorded to it.
   IV. Formerly it was a matter of great importance to mark out the
 place of necessity in the operation for empyema.   If there was  no
 manifest tumor or thickening of the tissues externally, if a cataplasm
 which should become dry at an earlier period, according to some, or
 remain  on  the contrary a longer  time moist,  according to others,
 when placed over the effusion,  indicated nothing, it would be neces-
 sary to depend upon the sensations experienced by the patient, or to
 succussion  or other means still more fallacious.  But the labors  of
 Avenbrugger,  Corvisart, Laennec, and M. Piorry, have  fortunately
 dispelled this uncertainty; so that now it is  almost as easy to recog-
 nize the precise seat and limit of collections in the interior of the
 chest, as if they were upon the surface of the body.
   B. Instruments.—Whether for  the purpose  of guarding  against
 hemorrhage, or for obtaining a wound with  loss of substance, or be-
 cause they  considered  escharotics to possess particular virtues, the
 ancients and many authors of the middle ages, in order to open into
 the  chest, frequently had recourse to  cauteries either chemical  or
 metallic.  The cotemporaries of Leonidas made use of a cautery in
 the form of the kernel  of fruit.   It was also by means  of the iron
 heated to a white heat that the Cinesias mentioned by Galen was ope-
 rated upon.  The cautery of Rhazes was slender and pointed, while
 that of Albucasis was of a triangular form.   A. Pare recommended
 that it should be provided  with  a concave plate at some distance
 from its point.  But this method, long since abandoned, would scarcely
 merit notice, if it had not been still eulogized by M. Gouraud, who
 especially uses  it for effusions of  pus, and  gives to the hot iron the
 advantage of enabling the abscess to empty itself of its own accord
 upon the fall of the eschar, and to the wound that of resisting the en-
 trance of the air from the tumefaction of its borders.  The scolopo-
 machairion of Paul of Egina, the phebotome of the Arabs,  and the
 sagitella of Arculanus, which were formerly made use of, have also
 disappeared from practice.   The  ordinary  bistoury  and trochar, at
 the present time, are substituted for all  other kinds  of instruments,
 when it is our intention to make an opening into the chest.   Though
 Pare had already proposed the paracentesis  trochar, in order to per-
forate one rib rather than the intercostal space, it  was not however
 until after  Drouin  and Nuck that attention was  really turned to-
wards this point.  Dionis, Heister,  and Morand especially advocated
the employment of the trochar, which has still a considerable number
of partisans at the  present day, and which  possesses the advantage
of rendering the operation easy, prompt, and attended with but little
 pain, and the entrance of air into  the cavity almost impossible; of
not making it necessary to evacuate the entire collection at first; and
 of permitting in fine the repetition of a considerable number of punc-
tures successively in cases in which this should be judged necessary.
   vol. in.                     24 
186          NEW ELEMENTS OF OPERATIVE SURGERY.

But as on the other hand its canula possesses the inconvenience  of
not always allowing a sufficiently free exit to matters that are some-
what  inspissated, or  grumulated pus, or blood  partially coagulated,
for example, it  is far from  being applicable in  all  cases  indiscrimi-
nately.   Moreover the preference is not generally given to it except
in hydrothorax and extensive pleuritic effusions.  There would  be
no difficulty moreover in transforming a simple puncture immedi-
ately  into a large wound, if the liquid at first did not run with suffi-
cient  freedom;  nor can I perceive how the lung or diaphragm would
incur  more risk of being wounded by such an instrument  than by
any other.   Paracentesis thoracis moreover is governed in other re-
spects by the  same rules as paracentesis  abdominis, which  will  be
treated of farther on.
  C.  Auxiliary Resources.—If our object in the operation  is to re-
lieve  an  effusion of air, the wound generally  requires no dressing.
In other  cases, the course  to  be  pursued is not so precisely estab-
lished.  In  truth, the pyulcon of Galen, the cupping glasses, syringes,
and suction, so much boasted of in the sixteenth and seventeenth cen-
turies, in order  to remove the very last drop of extravasated liquid;
the different kinds of canulas employed during a long period  of time,
in order to  prevent the pleura from closing up too  rapidly, and  to
enable us to evacuate the chest only by degrees, have lost almost all
their importance, although practitioners still ask the question whether
we ought or ought not to evacuate at once the  morbid collection,  or
to maintain a foreign body  there under  the  character of a filter,  or
throw up medicated  injections into the  cavity  rather than to  unite
the external opening by first intention.
  Unless the lung should possess all its natural expansibility, which
is  a very rare  circumstance in hydrothorax, there would be an un-
doubted  advantage in not allowing the serosity to escape except by
degrees, and in introducing  the extremity of a band of linen or meche
of lint into  the plural cavity, in order that at each dressing we may
procure an additional  discharge.   Perhaps  also repeated punctures
with  the cataract needle or a very narrow bistoury, would  deserve
to be  made trial of under such circumstances ; nor can I see why the
employment of this meche ought to be neglected in cases of empyema,
properly  so called, or in effusion of blood, so long as we attach impor-
tance  to the circumstance of air not penetrating into the cavity.   To
perform  the paracentesis, moreover, no other instrument is required
than  the trochar.  The  employment of injections requires  all the
attention of the surgeon.  It was the abuse which the ancients made
of these, which has  induced the  moderns to proscribe them almost
universally.  They are not applicable  either in hydrothorax or  in
those  effusions which are not limited  by any adhesion.  In the other
cases, on the  contrary,  it  would be difficult to contest their advan-
tages. As soon as the suppuration has a tendency to become degen-
erated, they alone appear to be capable of preventing adynamia and
the decomposition of the fluids, by modifying and cleansing the surface
of the morbid  cavity, and  by favoring the discharge externally  of
the altered matters in proportion as they are formed.  M. Billerey,
and M. Recamier (Bull, de VAcad. Roy. de Mid., t. I., p. 182,) after
him, whs substitute and retain in the cavity emollient, detergent oi 
EMPYEMA.
187
 antiseptic liquids, in place of the pus which they have extracted, have
 had every reason to be satisfied with this practice.  It is seen tnere-
 fore that the precaution of strongly stretching up the skin while we
 are perforating an intercostal space, in order to prevent the parallelism
 which, unless we should do this, would be left between the opening
 into the pleura and that of the integuments, can scarcely be neces-
 sary, and that it is far from meriting the importance which has  gene-
 rally been accorded to it since Bass laid it down as a precept.

                    § IV.—Operative Process.

   A convex or  straight bistoury, or a trochar, a vessel to receive the
 liquid, a strip of trimmed linen, a yard long and one finger's breadth
 in width, some  gateaux of lint and compresses, and a body bandage,
 form,  together with a canula of gum-elastic, and a syringe, all the
 articles that we can require.
   A. Ordinary Process.—The patient being seated on a bed, rather
 than on an arm or common chair, and more or  less inclined  to his
 sound side, is  to  be  supported in this position  by assistants in such
 manner that the intercostal space  which is to be  opened may be
 widened as much as possible and altogether  free.   The surgeon
 being placed upon the right and in  front, stretches the skin with his
 left hand, and with a bistoury in his right hand divides it in a direc-
 tion parallel to the superior border of the rib below, from left to right
 on the right side,  and from himself if it is on the left side; divides
 successively, and  in the same direction, layer by  layer, the adipose
 covering, a thin layer of cellular tissue, the external muscles of the
 thorax, if there are any at the point which he has selected, and the
 external and internal  intercostal  muscle; reaches  the pleura, and in
 order to perforate it without  danger of wounding other organs, then
 makes use only of the point of the bistoury, resting at its back on the
 pulp of the left forefinger, which serves him as*a director; gives  to the
 internal opening an extent of from six lines to an inch, and penetrates
 in this  manner  into the interior of the cavity,  from whence he will
 perceive that the liquid instantly escapes.  If, as frequently happens,
 layers of a new  formation should  have become adherent to the  inter-
 nal surface of  the  pleura, the operator will have so  much the less
 reason to be deterred by this difficulty, inasmuch as we may, if neces-
 sary, plunge into the  tissue of the lung  itself, when the abscess has
its  seat in that parV   The important point is not to strike outside of
the morbid collection.   In event,  however, of  making  a mi^ke of
this kind, it would be better,  unless the matter was at so small a ai&-
tance that we could appreciate its fluctuation with the finger, to  make
another opening in a suitable place,  than to persist in detaching the
neighboring adhesions, either by means  of the finger, handle of the
scalpel or sound, or what is more objectionable, by means of a blad-
der introduced  empty into the wound,  and  then  filled with air or
liquid while it is in the thorax, as  some of the ancients recommend.
  B. Process of the author.—The reasons adduced for laying down
so many precautions in perforating the parietes  of the thorax, appear
to me to be  but  little worthy of the approbation they have received.
What danger can there be in penetrating at once into the pleura, o- 
 188          NEW ELEMENTS OF OPERATIVE SURGERY.

 even in going into the lung?  But this accident is not possible, except
 the instrument should not be directed upon the collection.  Moreover,
 the lung is free and sound  behind  the wound, and then the pleura is
 no sooner perforated than the pressure of the atmosphere pushes the
 lung  towards the spine ; or intimate adhesions unite it to the walls of
 the chest, and in  this case what danger could arise from a  slight
 puncture of its  parenchyma ?  I am of opinion,  therefore, that the
 operation for empyema would be infinitely more simple, and in every
 respect as safe, if in order  to  perform  it we should suddenly, and
 without hesitation, perforate the intercostal space by means  of a
 puncture with the  bistoury, held in the second or  third position, that
 is to say, in  the same manner as in external abscesses, which are
 opened from within outwards.   We would  in this way combine in
 some measure the  advantages of paracentesis with those of incision,
 and the opening into the  chest, which appears so  formidable at first
 sight, would in reality scarcely deserve the name of an operation.  I
 have  performed the operation five  times by this process, and have
 not been able to comprehend what advantage there would have been in
 making use of others.   M. Caffort also writes me that he has several
 times had recourse to it with success.
   V.  Dressing.—1 designedly  omit speaking of the  precept of
 those who recommend that before incising the  integuments,  we
 should take up a large fold of them perpendicular to the ribs, in place
 of stretching them with the hand, and that of some others who have
 supposed that the  incision of the skin ought to be vertical and not
 horizontal.   It suffices to  mention  such opinions, to  enable  every
 person to appreciate  them at their  just value.  I  shall take still less
notice of the method of Mercati, which consists in penetrating only
as far as the pleura, and without wounding that membrane, in order
that the liquid may  of itself effect the  perforation.   It  would be
equally absurd to finish the  operation with a lancet, after making use
of the bistoury for  its commencement.  The object is to arrive with
certainty and without danger into  the  morbid  cavity.   Nothing,
certainly, can be less difficult, and it is not assuredly in this point of
 view that the operation of empyema should be deemed formidable.
   A.  An effusion to  such extent as to  require surgical aid,  might
cause the death of the patient, if it should be formed at  the same
time in both sides of the thorax, before we could venture to attempt
the operation.  Upon the contrary supposition, it would be necessary
to follow the rule  formerly laid  down by A. Benedetti: that is, not
to open into the  two pleural cavities, until after an interval  of some
days,  and to adopt all  the  precautions necessary to prevent the
crowding back and contraction of the two lungs.
   B.  If the  operator does not wish the wound to remain open, he
approximates its lips as soon as there is  no  longer any liquid to ex-
tract from the thoracic cavity, keeps them in contact by means of a
strip  of adhesive plaster, then  covers them with  a gateau  of lint,
followed by a compress, and secures the  whole by means of a body-
bandage drawn  moderately tight.   If the whole of the matter has
not been evacuated,  the  flat dressing  with lint  besmeared  with
 cerate, is generally sufficient to prevent  the  too speedy adhesion of
the borders of the perforation.  In order, however,  to  have our 
EMPYEMA.
189
minds at rest on this point, there  is no objection to the  surgeon in-
serting into the solution of continuity, by means of the meche-holder,
a small cone of lint or  one of the extremities of a linen band pre-
pared for this purpose: in other respects he is to proceed as above.
The  tents which  were formerly  employed  for  this purpose,  and
which were attached outside  by means  of a  thread, besides the in-
convenience of forming a plug, also possessed, as in the example re-
lated by Guy, that of the possibility of their escaping into the morbid
cavity and becoming lost there.
   C. So long as the fluids that flow out at  each dressing, preserve
their primitive character and do not deteriorate, injections could not
but be injurious.   We ought to have  recourse to them, on the con-
trary, upon the slightest change being manifested.   Under this point
of view, tepid water at first, sweetened barley water, diluted lime or
lead water, or a weak decoction of bark, are to be successively or alter-
nately used, also other detergent, astringent, or antiseptic liquids, which
the practitioner will know how to  select according to the indication.
M. Bache, (These,No. 66,Paris, 1827,) avers that this method which
has been for a long time adopted at the  Hospital of Grenoble by  M.
Billerey, who, moreover is in  the  habit  of closing the wound in the
interval of the dressings, by means  of a plug of gentian, has  been
frequently attended with complete success in that establishment.
   D. The apparatus contrived by  M. G. Pelletan, (Bull,  de  VAcad.,
t. I., p. 227, or Gaz. Med.,  1830,  p. 185,) and which by means of
canulas and valves, (soupapes.) permits the establishment of a double
current for the liquid, while preventing at the same time the intro-
duction of air into the  thorax, which  apparatus moreover is  based
upon the same principle as  that of M.  Heroldt, is  too  complicated
and of too litle importance for practitioners to assent to  its employ-
ment.   I would make the same remark of those which have  been
since proposed by MM. Bouvier, (Bull, de VAcad. Roy. de Med., 1.1.,
p. 73,) Maissiat, Recamier, (Ibid.,  p.  182,) &c.  The  small canula
provided with a perforated sac of goldbeater's skin,  made use  of by
M. Reybard, (Mem. surles Anus Artific <fcc, p. 157,) would be at once
more certain, simple, and convenient, if it were  advisable to  adopt
any precaution to prevent the  entrance of air into the thorax.
  [Paracentesis of the Thorax.—M. Trousseau,  (Arch. Gen.  de
Paris, 4e ser., t. VI., Sept. 1844, or Journal de Midecine de Paris,
Novembre,  1843, and Aout, 1844,) advocates  this operation, where
there is decided effusion and displacement of the heart, not only in
chronic but also  in  acute  cases  of pleurisy.   He has  performed it
once in acute, and twice in chronic pleurisy, and in both the latter,
as  he thinks, it saved the life of the patients.   Laennec had also long
since recommended it as a dernier resort in such cases, to prevent
immediate  suffocation.  Our  remarks on  tracheotomy, (see  notes
supra,) apply to paracentesis thoracis. As to the danger of the lungs
being  suffocated,  as  Laennec considered, by the compression  of
the diffused  fluid  in  the pleural cavities, this is doubtless possible,
where active depletion has been neglected.  But certain it is, that
one lung may be gradually almost entirely absorbed by compression
from such fluid, without causing death.  While at the Seamen's Re-
treat, I saw a striking case of this in a patient who died of a protract- 
190
NEW ELEMENTS  OF OPERATIVE SURGERY.
ed hydrothorax and general dropsy.  One lung was reduced down
to the size of a dog's ear, and  was floating in an ocean of circumam-
bient transparent  serum in the pleural cavity, and this without  the
normal organic structure of the lobes of this  miniature lung being
apparently in the  least degree altered !  T.]

     Article II.—Wounding of the  Intercostal Artery.

                              §  I.

  Upon the supposition that the diaphragm had been wounded, during
the  operation of empyema, an instance of which was witnessed by
Solingen, we  should have no other resources than those of medicine
to oppose to it, and the  wounding of the intercostal artery is, in fact,
the  only accident  which in these cases can require the interposition
of surgery.  Though rare, this wound, however, has occupied much
of the attention of authors, to so  great a  degree in fact, that  the
number of remedies that have  been  proposed  for its relief,  perhaps
exceed that of the number of  times that  the accident has occurred,
unless perhaps it be that it has.been frequently overlooked  and  the
proper remedy neglected, even  in  those cases  in which  the effusion,
which it has produced, has resulted in a fatal issue, an example of
which has been published by M. Thierry (Bibliot. Mid., 1828, t. L,
p. 240.)  The  cases  in which  it has been especially met with,  are
those from wounds penetrating into the chest.  It  is recognized by
the  hemorrhage which it occasions, the symptoms  of effusion which
follow, the paleness, syncope, &c.   A piece of card introduced  into
the  bottom of the wound and curved  into the shape of a gutter,
enables us to ascertain the direction from whence the blood escapes.
The finger glided under the rib will frequently distinguish a hot or
pulsating jet of blood  difficult to be  mistaken, and forms  one of
the  surest diagnostic marks when its employment is practicable.

                              §11.

  Gerard, by means of a thread  introduced  into  the  wound,  and
brought from within outwards by the aid of a curved needle,  through
the  intercostal space above, conducted a tent below the artery, which
he hoped in this manner to compress by constricting the entire cir-
cumference of the rib.   Goulard,  with the view of rendering it  un-
necessary to withdraw  the  whole  of  the  conducting instrument
through the new  wound, contrived a needle with  a  curved handle,
like that of Gerard, pierced with an eye near its point, and hollowed
out upon its convexity with a  groove which was intended to receive
the  thread.   Heuermann alleges that by means of  a needle strongly
curved and fixed  at an  angle upon its handle,  we may surround  the
bone in such manner as to bring out the two extremities of the thread
through the same wound.  Leber, after having made a second open-
ing above the rib, used  this opening to conduct a thread which he
caused to come out through the wound, and the two ends of which
he afterwards knotted upon a compress  after  the manner of Gerard.
To  effect this, he  made use of a flat and flexible sound, which Steidele 
             WOUNDING  OF THE INTERCOSTAL ARTERY.           191

has replaced by one of silver, curved into the shape of an S, and for
which Boestcher has, according to Sprengel, substituted a smooth and
blunt-pointed steel sound.  Finally, Reich, instead of fastening the
thread by a knot, recommends that  its extremities should be passed
through a gum-elastic canula, which is to be secured outside ; but all
these processes are useless, as well as the double plate of Lottery, the
jeton of Quesnay, and the machine of Bellocq.

                             § III.

   Nor does the tent strangulated in  its middle portion  by a thread
tied strongly around it, and then introduced transversely into the
pleura, and afterwards  placed in  a vertical position, in order that
when making traction upon it, it will no longer be possible to draw it
out, and that it may compress at the same time the artery  as well as
the borders of the two neighboring ribs, deserve the eulogies that
have been bestowed upon it by Bilgucr, Richter, Desault, and Saba-
tier.  Theden maintains that in order to arrest the hemorrhage, nothing
more is required than to complete the division of the artery, reverse
its posterior end backwards, and tampone the wound.  I will re-
mark that we may frequently effect the same result without reversing
the vessel, as has been shown by Hebeinstreit.   It is difficult to un-
derstand why Loefler should have thought it proper to recommend
an opening  into the intercostal space a little farther behind,  leav-
ing the pleura intact, in order to divide the  artery at this point, and
to  apply the tamponing  there, without interfering  in  any  respect
with the exit of the effused matters, through the first opening.

                              §  IV.

   Bell, rejecting all these  processes, finds it more convenient to seize
with a hook the end of the wounded vessel,  and to apply a ligature
to it immediately. There are those who have ventured to establish
a point of compression upon the wound of the vessel during the space
of several days, by means of the fingers of assistants alternately re-
lieved.   But upon the supposition that prompt action was necessary,
we might readily arrest  the hemorrhage by introducing after the man-
ner of Desault and Zang, the middle portion of a fine compress into
the chest.  After having filled the  bottom of this kind of sac with
lint or tow, to transform its internal portion into a pelote, there would
be nothing more to do than to shut up its external portion and make
traction  upon it,  in such  manner as to compress from within  out-
wards, until the blood had  ceased  to flow.   This small apparatus
moreover could be readily secured, by tying the free  portion  of the
linen for example, upon another pelote of lint.   This resource, the only
one  to which AL Larrey gave  his  assent,  when from any reason
whatever it was not judged practicable to attempt immediate reunion
of the wound, being applicable to all cases, and possessing the advan-
tage of being always at command, and of being  readily understood
by every person, ought to have  the preference over all the others,
and should unquestionably be substituted for them. 
192          NEW ELEMENTS OF  OPERATIVE Sl'RGERY.
         Article III.—Paracentesis of the Pericardium.

                        § I.—Appreciation.

   The idea of opening into the pericardium when filled with seros-
 ity, pus or blood, appeared so bold at first that many persons still look
 upon it as rash and unwarrantable.   Timid surgeons  have been de-
 terred  by it from the fear of wounding the heart.  Others reject it be-
 cause it might excite an inflammation which, from its situation, would
 speedily result in death.   The  difficulty of recognizing the  disease
 vyith certainty during life, and  the  objection that we should give re-
 lief only to one symptom, is the argument which  the  most judicious
 have adduced against it.   None of these  various objections, how-
 ever, are  of  a character to cause it to be absolutely proscribed.
 The skilful practitioner, aided by the explorative resources that sci-
 ence possesses at the present day, will rarely find  himself incapable
 of establishing a  diagnosis of effusion in the  pericardium.   The heart
 may be always avoided.  By evacuating a serous membrane of the
 liquid  which  has accumulated  within it,  we  disembarrass  it of a
 foreign body,  and the puncture is in this  sense more calculated to di-
 mmish  than to give rise to inflammation.   It is true that with the
 operation the  patient is exposed to great danger; but without it he
 is devoted to a speedy and certain  death.   If the paracentesis does
 not cure, it may at  least afford momentary relief.   Nevertheless it is
 unfortunate that experience should  have  furnished scarcely any elu-
 cidation ; and  that it should still present only ideas that are purely the-
 oretical upon a subject of so  serious a nature.   Senac,  who has been
 erroneously thought to have  been the first to propose puncture of the
 pericardium, gives no instance of it, and  the case imputed  to him by
 Sprengel relates, in reality, to hydrothorax.  Van  Swieten and H.
 Welse,  referred to by M. Rayer, express themselves still  more con-
 fusedly.   Nor does Riolan, who  speaks of it as a general suggestion,
 assert that it had  been performed in his time.  It is well known that
 the  pretended pericardium  that  Desault supposed he  had opened,
 was nothing else  than an accidental cyst.  We do not find that M.
 Skielderup has furnished  anything conclusive in support of his opin-
 ions.  It is also evident that the  collection which was  opened  by M.
 Larrey was situated external to the pericardium.   The three  obser-
 vations related by M. Romero,  (Bull, de la Fac de Med., t.  IV., p.
 273,) and the  substance of which has been given by M. Merat, are
 too imperfect not to leave the mind in considerable doubt.  The one
 that M.  Jowet (Bull, de Firr., t.  XIII., p. 233,) has  published in
 1827, as the first instance  of a successful result, is also incapable of
 removing all doubts upon  this subject.  But though it may still re-
 main to be demonstrated that paracentesis of the pericardium has
 e\e.r been  performed Up0n  living  man'  excePt perhaps in the case
which M. Warren has communicated to me ; facts are not wanting
to show indisputably that the perforation of this membrane does not
necessarily cause  death.  The thesis of M. A. Sanson furnishes many
proofs of thus.  M. Larrey also relates several, and I myself have col-
lected other examples.—(See Wounds of the Heart, Vol. II.) 
                PARACENTESIS OF THE PERICARDIUM.            195

                    § ll.-^-Operative Process.

  The pericardium, in its natural state, is accessible at a great num-
ber of points  to surgical means.  Effusions, by distending it to an
abnormal degree, would  enable it to be still more readily attacked.
  A.  Riolan maintains, and others have agreed with  him, that we
may puncture the pericardium by trephining the  sternum, an  inch
above the xiphoid cartilage.  This opinion,  revived as a new one,
and with all the necessary details, by  M. Skielderup, has found some
partisans among the  moderns.  Laennec, among  others, adopts it,
and  endeavors to demonstrate  its  advantages, which  are that of
avoiding with certainty the  internal mammary artery, that  of going
down inevitably upon the distended pouch, and of not making an open-
ing into the pleura,   Senac recommends that we  should make the
opening in  the fifth or sixth intercostal space, a little to the left of
the sternum, and that the trochar, introduced  at that point, should be
introduced  very obliquely  downwards, and  to the  right, until  it
reached the collection to be  evacuated.  Desault, in  order not to
wound  the mammary artery, made  his  incision more to the outside,
and did  not penetrate into  the morbid  collection until after having
identified its fluctuation by means  of the finger.  This also is the
method which is eulogized  by M. Romero, who, in place of the tro-
char of Senac, or the  blunt-pointed bistoury of Desault, preferred the
scissors for dividing  the  pericardium, after having raised  up a fold
of it by means of the forceps.  Finally, M..Larrey considers it better
to perforate from below  upwards, the space which separates the left
border  of the xiphoid appendix, from the cartilage of the  last true
rib;  that we would in this manner avoid the pleura, incur no risk of
wounding the peritoneum,  diaphragm, or internal  mammary ar-
tery,  and would strike upon the most depending part  of the  peri-
cardium.
  B.  Trephining  of the  sternum unquestionably is the most simple
process  which has been  proposed.  The bone which is thus perfo-
rated is soft, and  superficial, and destitute of  vessels  on both its sur-
faces.   It enables us to see and to  touch the pericardium before
opening it, and to forego the last stage of the  operation, which is the
only one that is dangerous, should the surgeon have misconceived the
situation of the  hydropsy.   The fluid  cannot be  effused  into the
pleural  cavity.  I see no  other inconvenience in it than that of
occasioning  a  loss of substance, which renders the immediate re-
union of the wound difficult, and which unavoidably places the in-
terior of the cavity in contact with the atmospheric air.   But is  it not
better to leave the perforation of the pericardium open, than to shut
it up before having removed the source of the mischief? Is not the
action of the air, in such cases, a result which  is rather to be desired
than  to be dreaded ?   The danger which the pleura incurs, whatever
precaution we may take to  avoid it, and also  the internal mammary,
in •the method of Senac, slightly modified by  Desault and MM. Ro-
mero  and Jowet, are certainly not  considerations that ought to out-
weigh the preceding  process.   The  process  of M.  Larrey, which
might possibly procure  the same result  as the  trephining of the
sternum, is  not  so easy of application  as its inventor  supposed  in
   vol. in.                    25 
194
NEW ELEMENTS OF OPERATIVE  SURGERY.
 subjects in whom oedema, infiltration, or embonpoint  exists, to such
 extent that the skin does not come into immediate contact with the
 external surface of the bones or cartilages of the thorax.  The branch
 of the mammary artery, moreover, which  crosses the anterior face
 of the' ensiform prolongation, is sometimes so  voluminous that  its
 division, which is almost unavoidable, might give rise to an alarming
 hemorrhage.  In conclusion, therefore, it would appear to me pru-
 dent  to  adopt the  advice of Riolan, which is also  sanctioned  by
 Boyer.   The crown of the trephine should be applied upon  the left
 half of the sternum, immediately above the xiphoid appendix, in order
 that it might fall upon the broadest portion of the anterior space  of
 the mediastinum.  The left forefinger introduced into the bottom of
 the wound  would then  enable  us to identify the fluctuation, and
 would serve as a guide for the  bistoury.   Having  opened into the
 pericardium, it would  become advisable to turn  the patient upon his
 left side, and more  than ever  to keep his chest in a position almost
 vertical, in order to give egress to the  liquid, which should be allowed
 to flow out  gently.   The dressing would  consist of a meche intro-
 duced into the orifice of the serous sac, a plumasseau besmeared with
 cerate, some compresses, and  a body bandage,  in order to support
 the whole, precisely  as in the operation for empyema.
  C.  Injections.—The idea of treating hydropericardia in the man-
 ner of a hydrocele, and of injecting an irritating liquid into the dis-
 eased cavity in order to promote adhesive inflammation, has nothing
 in it repugnant to sound reason, and those who have reproached M.
 Richerand for having suggested it, have done so improperly.   If the
 puncture, besides evacuating the liquid, does not  in itself cause adhe-
 sion, it is useless to  count upon its affording relief, except as a sim-
 ple palliative.   The  radical cure of hydropericardia  without oblite-
 ration of the altered sac is no  more possible than that of hydrocele.
 If it ever has  been obtained, it is because  the practitioner, without
 having  intended it, has carried out the indication first proposed by
 M. Richerand, and since by Laennec.   The contact of the air, more-
 over,  would perhaps suffice to bring about the necessary degree of
 inflammation.   When there is no organic lesion,  tepid water or some
 other liquid only slightly irritating, should be  first  made trial of.
 Should  the case be one of effusion of pus, the  injection should be
 varied according to the indications, in the same way as after empye-
 ma.   In whatever manner performed, I should recommend that the
 incision  into the  pericardium,  when  the  bistoury is  made use of,
 should be large, and  that it should be kept open until the termination
 of the treatment.  The treatment would be then analogous  to that
 of hydrocele by incision or excision, and the effusion which generally
 follows the injection of the tunica vaginalis after puncture would not
 jeopardize the final  result.   If the case should be one  of serous
 effusion, I should prefer after having laid bare the part, to plunge in a
 trochar and after having emptied it  to inject it, with a solution of
 tincture of iodine, as is my general practice in hydrocele.  It is pro-
 bable  that we might in this  manner effect an agglutination of the
pericardium to the  heart.  These however are  nothing more  than
suppositions.   Before attaching any value to them or applying them 
PARACENTESIS OF  THE ABDOMEN.
195
to 'living man, we  ought, by experiments upon living animals, to
ascertain how far they are founded on truth.  It is a point in practice
which cannot cease to be interesting.  The rarity of the cases which
would  enable us to take advantage of it is the only  plausible reason
which appears to me to diminish its importance.
PART  FOURTH.

       ABDOMEN.
                         CHAPTER  I.

                 EFFUSIONS, CYSTS AND FISTULAS.

                    Article I.—Paracentesis.

   Puncture of the lower belly in cases  of dropsy is one of the most
 ancient operations of surgery.   The first suggestion of it must have
 been derived from accidents, of which history furnishes a great num-
 ber of examples.  Nothing in fact is more common in the annals of
 science, than cases of ascites cured in  consequence of a wound of
 the abdomen.   A child, says Meysonnier, (Cours de Med., 7th edit.,
 4to, p. 276,) who was amusing himself in playing with a knife in the
 yard  of a peasant who had  ascites, was thrust by his  little  compan-
 ions against the  unfortunate patient, and  cut  an  opening into his
 belly.  A great quantity of water ran out through the wound, so that
 at the expiration of  a few weeks the patient found himself radically
 cured !  Another ascitic, finding no surgeon willing to undertake the
 puncture, resolved to perform it  himself.  Prohibition having been'
 made to allow any thing to  be  placed  at his  disposal which  could
 enable him to carry out his intention, he  concluded to break the glass
 which he used for drinking and shape out a piece of it, which he
 plunged in below the navel.  A radical  cure was the reward of his
 temerity.   There is no doubt that the same circumstances have  led
 to the same  result in the remotest antiquity, and  that paracentesis
 abdominis is as ancient as medicine itself.  A patient operated upon
 by M. Isabeau, though affected  at the same time with hydrothorax
 was perfectly cured of his ascites.  M.  Dupasquier, who in anothei
 case had recourse to diuretics after puncture, was no less fortunate.

                        § I.—Indications.

  •When  the ascites is the result of an incurable affection of  one of
the organs contained in the belly,  it is evident that puncture  canno'
cure it, and that  we must then resort to this only for the purpose of
procuring temporary relief to the patient.  But if the dropsy is essen-
tial and  idiopathic, the extraction of the effused liquid cannot  but
favor the  action  of the general  treatment and co-operate in the re- 
196
new elements  of operative surgery.
establishment of the health.   In the first case we should not operate
but at as late a period as possible,  and to prevent suffocation; in the
second case, it would be advisable to adopt the recommendation of
Duverney and Bertrand, as revived by Broussais, and give egress in
good season to the effused  liquid.
  A.  Compression.—It is  so seldom that  we see ascites terminate
fortunately,  that after having unavailingly made trial of  the means
that experience  appears to have placed most confidence in, for exam-
ple, compression, which I have seen succeed in one instance in a boy
fourteen years of age at the hospital of Tours, in 1818, and the advan-
tages of which are eulogized by M. Speranza (Bibl. Mid., 1829, t. II.,
p. 242,) and  M. Godele, (Revue Med., 1831, t. I., p. 12,) and the good
effects  of which were recognized at the Hotel Dieu in  1831, and its
efficacy since placed beyond all  dispute by M.  Bricheteau, (Arch.
Gin. de Med., t. XXXIIL,  pp. 75—93,) it is allowable to appeal from
these modes to the operation, however feeble may be the hope of its
success.  It  must be that MM. J. Darwell and J. Copeland, (Cyclop.
of Pract. Med., vol. I., p. 169,) who were  desirous of having it pro-
scribed in practice, and who have advanced against it a great number
of unmerited reproaches,  have not seen it employed in practice,  or
have been rarely witnesses  to the distress which ascites  sometimes
occasions.
  B. Temporary blisterings, recommended by  Trouve, (Arch. Gin.
de Med., t. XVIII., p. 200,) have been employed by myself of a size
which might be called monstrous,  and in my opinion deserve farther
trials.
  C. Encouraged by what Thouvenot says of his needles and small
canulas, by  what I  have seen myself, and by what has been stated
in England, of acupuncture  in hydrocele, I was desirous also  of
making trial of this  method, after the manner of M. King, in ascites.
Having plunged in  upon five or six points of the belly a  long com-
mon or cataract needle, and having repeated this process three or four
times  in  the space  of fifteen days upon two women, I saw an im-
provement take place which surprised me, and which  would justify
additional trials of the same description.

             § II.—Examination of the Processes.

  A.  The red hot iron formerly used, caustics by which  an ulcer was
first made,  and which it was afterwards  necessary to lay open in
order to reach  the  peritoneum, together with  the  seton,  as recom-
mended by others, have long  since given place to more rational pro-
cesses.  The method of Paul of Egina and Guy de Chauliac, which
was still  lauded by  Pigray, and which consists in dividing the integu-
ments by means of  a bistoury, and then perforating the aponeurosis
or muscles  a little  higher up, in  order to be enabled to  shut up at
pleasure  the deeper wound, by allowing the skin, which  had been
previously raised up, to glide over in front of it, has been  also aban-
doned, as well as  all those which were performed by means of a
cutting instrument.                                •
  B.  The needle, and the small  canulas  of Thouvenot,  (Planque,
Bibl., t. V., p. 665,)  or of Barbette, evidently indicated by Rhazes, the 
PARACENTESIS OF  THE ABDOMEN.
197
instrument of Block or Girault, and the trochar canula of Sanctorius,
the invention of which Camper pretends to trace up to Hippocrates,
variously  modified  by others, especially by J. L. Petit, who con-
structed from it the instrument known at the present day under trie
name of trochar or trois-quarts, render the puncture of the abdomen
so simple  and  easy, that for a century past there is no longer any
more question of the bistoury or lancet than of the cautery, when our
intention is to penetrate into the peritoneum for ascites.
   C.  Some modern surgeons, however, seem desirous of reviving the
method by incision.  Physick, among others, alleges that the opera-
tion is much less  painful with the lancet than with the trochar, and
Dorsey says that in America this last mentioned instrument will soon
fall into disrepute.  M. Callaway, a surgeon  of London, has more
recently endeavored to  prove that we ought in reality to give prefe-
rence to  the lancet in  puncturing the lower belly.  Guided by the
left forefinger, which serves as a point d'appui to it, we introduce it
with  the  right hand on the linea alba above the pubis;  we  then im-
mediately insert, through the wound into the cavity of the peritoneum,
a  female  catheter, when the operation has no longer anything parti-
cular.  This process, which had  already been  proposed by Petit-
Radel, and which is the same in  fact  as that  of Ccelius Aurelianus,
might be  followed without inconvenience ; but it is doubtful if in fact
it  possesses any real advantages over the method adopted among us.
If the cutting instrument encounters any vascular branches, it divides
them unavoidably, and all the organs within its  reach will be exposed
to the same casualty;  while the trochar separates apart, and rather
displaces  than divides the movable organs which present themselves
in front of it.  The wound made by its passage immediately closes
as soon as the  instrument is withdrawn.   That which the lancet
makes, on the  contrary, remains open, and presents no obstacle to
the egress of the serum  through it.
   D.  The flat trochar of Wilson, or the flattened one  (meplat) of
Andre, which, by the advice of B. Bell, many  practitioners  in Great
Britain prefer to Petit's  instrument, because as  they assert it scarcely
differs from a cutting  instrument, is wholly undeserving of such a
predilection.   The jointed trochar, those  in which  the point is con-
ical, serpent-tongued, or more or less flattened, in place of being tri-
angular, together with  the fifty other descriptions which have been
extolled, are not worthy of being mentioned.  The one which has re-
ceived the approbation of the French surgeons leaves nothing to de-
sire, and the modifications which have been attempted upon  it since
the time of J. L. Petit are calculated only to render it less perfect.
   I.  Place of election.—All parts of the belly  are not equally suita-
ble for paracentesis.  The left flank would be  more favorable when
the spleen is sound, if the epiploon, which extends further upon this
side, did not present any obstacle to the egress of the liquid.  Upon
the right  side we  should have to fear the presence of the liver;
while were we too near to Poupart's ligament, we might encounter
the sigmoid flexure of the  colon  or the caecum.   Posteriorly, we
have  the last false rib or crest of the os innominatum, and we might
readily wound the lumbar portion of the colon.   The supra-umbil-
ical zone corresponds to the transverse portion of the large intestine. 
 198           NEW  ELEMENTS OF  OPERATIVE SURGERY.

 Far down upon  the median line we encounter the bladder.  We
 must select, nevertheless a depending part.  The linea alba, preferred
 by the ancients, and even still by most English surgeons, has no  ad-
 vantage  in  this respect; and it  is far from protecting us with as
 much  certainty as  has  been supposed, from every kind of hemor-
 rhage.  A large vein sometimes runs over its posterior surface, and
 M. S. Cooper mentions a case  in which more than a  pint of blood
 came from a wound which he made in this place with a bistoury.
   a. In women there is found between the womb and  the rectum at
 the bottom of the  pelvis, a cul de sac, by which we could  readily reach
 through the  postero-superior part of the vagina.   This, which is the
 most depending point of all, would also be perhaps the most suitable,
 if the peritoneum were  free throughout its whole extent, and if any
 change whatever  in  the relations of the bladder, uterus, or intestines,
 would not unavoidably expose to the risk of perforating one of these
 organs.  We ought not  therefore to select it, nor to conform to  the
 rule  laid down by Henckel, Watson, Bishop, and Noethig, until after
 having satisfied ourselves  by  the touch,  that the  serum  had  de-
 scended down as  far as  the pelvic cavity, and that it has a tendency
 to depress the upper part of the vagina.
  b.  In penetrating  by the rectum above  the vesiculse  seminales, as
 some other practitioners recommend, there would be still greater dan-
ger of wounding the bladder. The danger of finding stercoral matter
afterwards passing through the rectum into the peritoneal cavity, will
 be sufficient to cause  this route always  to be rejected, though it
 might be adopted in certain cases as an exception.
  c.  Even the bladder has been perforated for the purpose of empty-
ing the peritoneal cavity of dropsical patients.  M. H. Berard men-
tions a case  in his thesis. A case was thought to be ischuria.  The
sound was forcibly introduced into the urethra, when several pints
of serum escaped, and the patient died.   The opening  of his  body
proved that  it was ascites, and that the instrument had  entered  into
his belly.  A surgeon of London, M. Watson, has gravely proposed
to penetrate designedly  by this route, and what is not less surprising,
one of his countrymen, M. Buchanan, states that he has done it  in
three instances with success ; but it will never be necessary among us,
 I think, to seriously  undertake the refutation of a principle like this.
  d.  The scrotum, which is the best route, as the observations of Le
 Dran and Morand  show, when  there is  at the same  time ascites
 and  congenital hydrocele, can be applicable only under these cir-
 cumstances.   If we should  meet witf a region in the abdominal pa-
 rietes more  attenuated  than others, to such degree as to be  formed
 only by the  skin, and to  have acquired a sort of transparency, this is
 the place we should select, however unfavorable it may be  in  other
 respects.
  e.   The navel,  which frequently  presents this  peculiarity, and
 which Lanfranc and the two Fabricii recommend, is the point which
 M. Ollivier,  (Arch. Gen. de Mid., t. VI., p. 178,) on  the strength  of
 a fact occurring in  his own practice, and on another in that of M.
 Bigot of Angers, proposes to perforate in pregnant women,  Scarpa,
 (Bull,  de Fir., t. II.,  p. 256,) on the  contrary, and after him  M.
 Langstaff, (Arch. Gin.  de  Mid., t.  VIII., p. 267,) or M. Cruch, 
PARACENTESIS OF THE ABDOMEN.
199
recommend that during pregnancy the puncture should be made in
the left hypochondrium, that is, a little below the third false rib. Like
M. Emery, who says he has performed it six times in a single female,
I have had recourse several times to paracentesis in women in the
state of gestation, and three times, among others, during the same preg-
nancy.   The whole extent of the left flank and all the points  on this
side where the trochar is usually applied, have seemed to me, separa-
ted from the womb by an interval of too great  an extent to make it
necessary to attach much  importance to the precepts of Scarpa.
  /.  A little to the outside of the  tinea alba where the puncture was
formerly made according  to' the recommendation of Celsus, we incur
some risk  of wounding the epigastric artery.   The middle  of the
space that  separates the ribs from the spine of the ilium, as indicated
by Sabatier, would have  the inconvenience of being too  near  the
chest,  should the spleen and the liver be affected with any engorge-
ment ; so that, as a general rule, the middle of the line which extends
from the  umbilicus to the antero-superior spinous process  of the
ilium is  still the one which should have the preference.   Here the
instrument can touch neither the  bladder nor the womb, unless either
should be very much developed, nor the epigastric artery which is on
the inside, nor the anterior iliac artery which is to the outside, nor
the colon which is behind and below.   This place, which the ma-
 jority  of operators have recommended should be chosen since Palfin
first suggested it, is therefore the true place of election, and  any of
the others the place of necessity.
   g. In  ordinary  ascites the wounding  of  the  intestines or their
arteries is next to impossible.  The contained serum must naturally
push them  towards the diaphragm or in the direction  of  the spine.
Though they should even remain free and floating, the mesentery is
not long enough  for  the trochar  to reach them.  But  should a
noose of  intestines  have become  adherent to the walls of the abdo-
men, there  is no doubt that the instrument might open into them and
give egress to foecal matters, examples of which are on record.
   II. Encysted dropsy, which may have its seat in an  ovary, in the
cavity of the epiploons, in a portion of the peritoneum limited by ad-
hesions, or in  some particular accidental  sac, would also incur the
risk of the  same accident.   Being surrounded by thick walls  we are
compelled  in most  instances to penetrate deeper, sometimes, accord-
ing to Mouton, to  the distance of four inches before  reaching the
collection,  which consequently makes it necessary that it should be
identified if possible before commencing the operation.
   III.  Position of the patient.—No one at the present day  recom-
mends that the patient should stand up during the  operation, nor ex-
cept under certain circumstances  is it convenient for him to be seated
in a chair.  The proper position for him is upon his side and very near
the edge of the bed.   While the liquid is running out, an assistant,
stationed upon the opposite site, gently compresses the walls of the
belly by means of his two hands broadly spread out.  Without this pre-
caution, which the ancients neglected, the viscera and the large vascu-
lar trunks,  suddenly deprived of the pressure to which they had been
habituated, might  give rise occasionally to syncopes, swoonings  and
convulsions, all of which  it is important  to avoid.  The  species of 
fiOO           NEW ELEMENTS OF OPERATIVE SURGERY.

bandage or corset contrived by Monro, as a substitute for the hands
of an assistant, and to be used after the operation as the dressing,
though very ingenious, does not, inasmuch as it but imperfectly ful-
fills the indication, merit  the preference which some persons have
accorded to it.   To apply it beforehand and tighten it by degrees as
the belly is emptied, to maintain  opposite to  the  proper  place, the
hole which it has on its side  for the passage of the trochar, and after-
wards to pad the cavities which might  be left in the direction of the
iliac fossae, &eM are details too trivial to engage the attention of sur-
geons, unless they should be necessary.  The folded sheet passed
around the belly, and the two extremities of which  are  gradually
drawn upon  by two  assistants while the water  is running out, as
recommended by M.  S. Cooper, would  be still more objectionable.
If the effusion has its  seat in the peritoneal cavity, it  is possible that
the epiploon, or a noose of intestine, or a flocculus of albumen or an hy-
datid, may become entangled in the extremity of the canula and shut
it  up  before the liquid is  completely withdrawn.  A stilette or any
blunt-pointed rod whatever, passed through the instrument, will  be
found sufficient to push aside these substances, and to give the pas-
sage of  the liquid all the freedom it had at first.   As serous cysts do
not scarcely ever contain anything but limpid serosity, they are gen-
erally exempt from this inconvenience; but dropsy of the ovarium,
which almost always consists of an oily or gelatinous matter, more or
less inspissated, of a yellow, reddish or darkish color, and  rarely of
great  fluidity, sometimes presents this difficulty, and requires at least
the employment of a canula of somewhat large dimensions.
  IV. Extraction of the  liquid.—Many  authors  have  considered
that we  ought not to remove all  the  contained fluid at once, but
that it would be better to  extract it  by degrees.  It was for this
purpose  that Paul of Egina, Guy de  Chauliac, &c, avoided  per-
forating  the skin and peritoneum  at the  same point; that already
at the time  of  Hippocrates they  were  in the  habit  of placing
in the wound a small canula which  has since  been modified  in
a thousand different ways, and which was made use of in some re-
spects as a faucet for plugging up  or  unplugging the  opening  at
pleasure; that  others  extracted first only a  small quantity of the
liquid fluid to return  afterwards  to the repetition  of  the same ope-
ration a greater or  less number of times;  and  that it  was  pro-
posed, after having opened into the  belly with a lancet, to leave the
matter to ooze out gently and imperceptibly of itself.  But as expe-
rience has furnished no positive evidence of the utility of this method,
it  appears to be more rational  not to leave in  the belly anything
but that  which cannot be extracted from it.  The exhaustion and the
syncopes which  the ancients expected  to prevent by acting in this
manner,  are still more effectually prevented by means of a bandage
suitably applied, and patients, after having submitted to this operation,
would be poorly satisfied  if their belly was but partially emptied.
   V.  Dressing.—The compressing bandage after the puncture, not
only has the advantage of supporting the viscera, but is also a power-
ful auxiliary in effecting a radical cure.  The authentic facts in sup-
port of this assertion are now sufficiently numerous to induce us to
add to their number more and more.  In  the  spring of 1831, I was 
"PARACENTESIS.
201
desired by M. Rousseau, a physician at Batignolles, to punctuie the
abdomen in a child five years of age, affected with ascites during tne
previous 8 months.  We withdrew six litres of limpid water from the
abdomen.   No alteration in the viscera could be recognized through
the walls of the belly.   A methodical and gentle pressure was imme-
diately applied ; the effusion was not reproduced, and the little patient
soon recovered its former health.  M. Fenoglio, (Gaz. Med., 1832, p.
588, 589,) in  operating on a woman 22 years of age, whose belly
contained 36 pounds of water, and afterwards on a man aged 40
years, and from whom 40 pounds of serosity were extracted, succeed-
ed equally well in both cases.  The manner of applying compression
in such cases, must be left to the discretion of the operator.   Whether
we make it with a flannel  band, as recommended by M. S. Cooper,
after the advice of Bell, with Monro's  bandage, or with a sort of lo-
sange terminated in a scapulary above, and by infra-crural bandages
below, in  such a manner that it may be conveniently tightened  trans-
versely; or make use  simply of a body bandage, and compresses or
other  napkins folded  in various ways upon the hypogastrium and
flanks ; provided the compression is methodical and regular, the rest
is a matter of little importance.  Large  temporary blisters after the
puncture in patients who cannot support  compression, would proba-
bly afford more chance of success than before the operation.
  VI. Injections.—Some  persons think  that the radical cure  of as-
cites might be accomplished after the puncture, by adopting another
method.   Noticing what happens in hydrocele, they have proposed
to throw up into the peritoneal cavity irritating  liquids,  in order to
favor its adhesive inflammation.  Brenner, who appears to have been
the first to make this suggestion, and who had no other  object than
to give tone to the viscera, proposed a solution of camphor, aloes and
myrrh in brandy.  Warick made trial of it and cured his patient.
Repeated with red wine and tar water, these injections were not at-
tended with the same  success,  and the two women died.   Warrick,
after having made trial of  the process of Hales, who recommended
that a canula should be placed on each side of the belly, in order that
the liquid  might be enabled to  run out of one while the injection was
thrown up through the other, ultimately gave a preference to Bristol
waters and simple puncture.  Though since recommended by Heuer-
mann, Bossu, and others, injections in ascites were wholly proscribed,
until a few years since the annals of Broussais brought to their support
two cases of  success  obtained by means of the vapor of wine.  M.
Lhomme, (Arch. Gen. de Mid., t. XIII., p. 282,) emboldened by these ex-
amples, ventured to make trial of the same process in an adult who had
already several times  undergone puncture.  The result exceeded his
hopes.  His patient, as well as that of M. Gobert, and that of M. La
Faye, (Lancette Franc, t.  II., No. 88,) continues to  enjoy excellent
health.  A question of so serious a character, requires  more conclu-
sive facts before it can be solved.   There is nothing  to show that M.
Lhomme actually caused the vapor of wine to pass into the  belly.
He filled, he says, a  syringe with it, but the linen wet with cold water,
and with which he thought it necessary to wrap the  canula, through
which the vapor had to pass, must have necessarily condensed it im-
mediately ; so that very probably it was  air, and not wine, injected
  vol. in.                     26 
202
NEW ELEMENTS  OF OPERATIVE  SURGERY.
into the abdomen.   The patient operated upon with it by M. Dupuy,
(Arch. Gin. de Med., February, 1832. t. XXVIIL, p. 271,)  died.
The cases of M. Jobert, (Lane Franc, No. 70, 73,) like those of
Heuermann, Litre, Garengeot and  Bossu, appear to have reference
only to encysted dropsies, or not to have been followed by a radical
cure, while those of Warrick are too imperfect to claim any great de-
gree of confidence.  The patient cured  by M. Vassal, (Soc de Med.
Prat., 1833, No. XII., p. 8,) by means of puncture, massage and irrita-
tions with the beak of a canula of a trochar, was followed by too many
serious accidents to embolden practitioners to make trial of the remedy
that saved her life.  Nevertheless, it is  not improbable that we may
succeed ultimately in obtaining  from these trials an important point
in practice.
   Reasonings based upon numerous facts induce me to believe that
the cure  of ascites only takes  place by means  of adhesion of the
parietal lining of the peritoneum with the abdominal viscera.  The
colics which those who  have escaped  from this disease  habitually
experience,  and the disturbance that they are troubled  with in their
digestive functions, would constitute the proof of my assertions.  A
man about fifty years of age,  cured of an ascites fourteen years be-
fore, and who died of pneumonia at the Hospital of Tours, in 1817;
and the young  girl nineteen  years of age, cured at fourteen  years
of age of a  similar dropsy at the Hospital des Enfans, and who died
in consequence of a cerebral lesion in 1824 at the Hospital of Perfec-
tionnement,  had both of them  all the intestines glued together and to
the walls of the abdomen by  innumerable cellular lamellae and fila-
ments.   Such being the  fact, it remains to ascertain whether pru-
dence and humanity would authorize us to imitate, under these cir-
cumstances, the processes of nature.   With  a  view of elucidating
this fact,  M. Bretonneau and myself,  in  1819,  made some  experi-
ments upon dogs.  We  injected into their  peritoneal  cavity, first
pure water,  then brandy dilated  with water, and finally water strong-
ly impregnated  with muriate of soda; but no inflammation could be
excited in these animals, and all  the liquids injected were absorbed at
the expiration of a  few days.  A patient in whom there  was no hope
of effecting  a cure by the usual remedies, and who was threatened
with immediate death, was submitted to the  same experiment.   He
died, but  in consequence of his dropsy and from a  portion of the
liquid which had become effused into the substance of the walls of
the belly having caused  there a gangrenous  erysipelas.  M.  J. Clo-
quet has frequently mentioned to me a patient in whom a vinous or
alcoholic  injection for congenital hydrocele  had, contrary to his in-
tentions,  passed into the abdomen, but who nevertheless after some
unpleasant symptoms was ultimately cured.   Without wishing to
deduce from those various trials conclusions which are not tenable, I
nevertheless think them worthy of attracting attention.  They go to
show at least that injections into the peritoneum  are not as formida-
ble as is  generally supposed, and that before passing upon them an
absolute  condemnation,  it would be  advisable to  make them the
subject of varied experiments and of an impartial and  profound in-
vestigation.   M. J.  V. Roosbroeck,  (Rev. Mid., 1832, t. I.,  p.  250,)
having been struck with the  diuret c  and sudorific property of the 
PARACENTESIS.
203
gaseous  oxide of azote, (gaz oxidule d'azote,) concluded to inject it
into the abdomen of dropsical patients after puncture.   Three pa-
tients, a man and two women, submitted by him to this treatment,
derived such advantages from it that Broussais in his turn ventured
to make  trial of it,  but  in a patient who was in so desperate a con-
dition that it was surprising to find he survived it even the period of
eight days.   The author puts two gros of nitrate of ammonia  in a
glass  phial,  to which  he adapts a  bladder with  a faucet; lutes this
apparatus and places it over the  flame of an alcohol lamp; allows
the bag to become filled with gas by the  decomposition of the salt;
unlutes it and waits until the whole has cooled ; places the extremity
of the faucet in  the opening of the canula of the trochar, and then
immediately proceeds to injecting  it.  If  there is no error in the ac-
count of M.  V. Roosbroeck, there is no doubt that  practitioners should
be solicitous to repeat his trials,  which M. La Faye has also found
reason to be satisfied with.  From what I have seen of iodine injec-
tions  in  hydrocele  and  serous cysts,  I am induced to believe that
they would afford  much better chances of success than  wine, in
ascites and  cysts of  the  abdomen.
  VII. A bladder of gold-beater's  skin.—A bladder of gold-beater's
skin, in the manner it is applied in the radical cure of hernia, as pro-
posed by M. Belmas, introduced empty, then distended or filled with
a suitable liquid while it is in the  peritoneum or cavity of the cyst,
and maintained  at  the  outside  by its extremity—could it  have, as
the author thinks, the  advantage of graduating the irritation at plea-
sure, and of even suspending it if  necessary by enabling us to with-
draw the foreign body which has produced it ?    I would not dare to
hope for this result.
  VIII. On the supposition that nothing of this kind has been done, and
that the effusion has reappeared, the puncture must be repeated again
and as often as becomes  necessary, proceeding in other respects ac-
cording to the rules laid down above.
  There  are patients  in whom life may be  thus prolonged for many
years, and in whom we  have to  have recourse  to  it every two or
three months.   Dropsy of the  ovarium, which is a purely local dis-
ease in most cases, is  the one which supports these repeated  opera-
tions the best.  Partial or encysted dropsy  has also, in certain cases,
been unquestionably benefitted by it;  but  it is  doubtful if general
ascites can be classed in the same category, or continue after the ope-
ration  of paracentesis so long  a  time without  terminating fatally.
Thus, when we  find it affirmed that puncture has  been performed
9 times on the same woman by Saviard, 11 by  Litre, 29 by Grew,
57 by Cheselden, 47 by Laub, 86 in the space of  26 years by  Marti-
neau, 52 by Schmucker, 65 by Mead, 100 by Callisen, 187 by M. Ro-
loff, (Revue  Med., 1826, t. II., p. 148,) in  a woman who performed it
upon herself 62 times, near 200 times in another  case, (Journ. Univ.
des Sc Med.,t. III., p. 119,) and even 655 times by Bezard, (Bull, de
la Soc Med. d'Em.,  No. 12, Dec. 1812,) and that the  fatal issue of
this malady has been  thereby procrastinated, it is next to certain that
the cases under consideration were dropsy of the ovarium and not
ascites, properly so called.   It was in the case  of  an  ovarian  cyst 
204
NEW ELEMENTS OF OPERATIVE  SURGERY.
that I was obliged to perform it 37  times in one woman, and 29 in
another in less than three years.

                    § III.—Operative Process.

   The various articles are composed of a trochar of two lines in di-
ameter, armed with its canula and besmeared with cerate ; a tub or
any large vessel whatever suitable  for receiving the liquid; a smaller
and deeper vessel which can be held near the belly, if the serum does
not run with sufficient force to render it unnecessary; a portion of
adhesive plaster; various compresses folded several times; a napkin
in the form of an ecusson; another napkin  folded in a  triangular
shape and with infra-crurals  and its scapulary attached.  An assist-
ant is stationed near the  head,  and  one towards the feet and the side
upon which the patient is laid, in order to support his chest and  the
upper part of the thighs.   A  third  stationed upon the opposite side,
or even on the bed, should he apprehend  that he  may  be  otherwise
too much fatigued, holds himself in readiness to place his hands flat-
wise over  the whole surface  of the belly, in order to  make  gentle
compression upon it in proportion as the liquid escapes.   The sur-
geon seizes the trochar and plunges it with his right hand through the
abdominal wall, the teguments of which he has kept stretched with
his left.  Forced in suddenly, and jn an energetic  manner, the instru-
ment  scarcely gives the patient any pain.   Many authors, fearing
that it might go too deep and wound  some  of the viscera, prefer in-
troducing it gently while turning it upon its  axis, and  suppose that
they escape still better by this means the danger of wounding any
arteries.   Arguments like these have no foundation.   The organs of
the lower belly are, as I have  already said, too  remote  from  its pa-
rietes in ascites, for the trochar to touch them, even though it should
be plunged in up to its handle.  Nor  is there any greater necessity
of obtaining a point  d'appui with the two last  fingers  on the skin,
while we are introducing it.   Such precautions moreover are only
calculated  to render the operation more difficult and protracted.
The forefinger or thumb elongated upon the stem of the trochar,
while the palm of the hand firmly embraces the handle  of the instru-
ment, leaves naked only so much of it as we wish, and as is required
for reaching the collection of liquid, and will secure us from wounding
the viscera.   Should the walls of the belly or cyst be one, two, or
three inches in thickness, so much so in fine as to embarrass the ope-
rator, an instance of  which Saviard states that he has met with;  or
should they be so flabby as to yield under its pressure, we would em-
ploy another  instrument, and it  would be under such circumstances
that the bistoury or lancet might be substituted with some advantage.
When there is no longer any resistance to  the  instrument, it  shows
that we have entered into the peritoneal cavity.   The canula, which
is to rest in its place with the  mouth directed downwards, is held
there by means of the left thumb and  forefinger, while the trochar is
being withdrawn  from  it.   The liquid escapes  immediately with
more or less force, and with a jet which  may then be readily direct-
ed into the tub destined to  receive it.   The  blunt-pointed  probe
chest sound, &c, are only useful in cases where some  foreign body 
                         PARACENTESIS.                      205

has got introduced into the canula.  All the water being extracted,
the operator withdraws the canula by rotating it on its axis, and at
the same time supports by means of the two first fingers of his other
hand, the periphery of the aperture he has made, to prevent the skin
from  being drawn upon it;  applies  over this point the plaster, and
compresses; in this manner dresses the whole front of the abdomen
and the sides; adjusts the body bandage and immediately places the
patient in the  middle  of his bed, and in the position which is least
fatiguing to him.

                       § IV.—Accidents.

   Hemorrhage occasioned by puncture, though a rare occurrence,
is however the inconvenience which has most  attracted the attention
of practitioners.   M.  C. Smith has collected ten examples of it.   It
is easily arrested when it arises from a  wound of the epigastric arte-
ry, or any other vessel in the parietes of the abdomen.   Various
means are used for this purpose ; one  of them employed in the last
century as recommended  by Petit-Radel, and which M. Cruveilhier
states that  he has made use  of with advantage, consists in including
a large fold of the soft parts in the  track of the trochar, then com-
pressing it, and even making friction  upon it slightly with the thumb
and forefinger until the blood has ceased to flow.  A small plug of
wax, the extremity of a rat de cave candle, cut in the form of a peg,
as recommended by Bellocq, or what is better still, a piece of gum
elastic or plastic bougie, such as we  make use of for the  urethra, in-
serted into  the wound  in such manner as to fill it up exactly, is a re-
source which in this respect  appears  to  me to leave nothing  to be
desired.  I  do not know  however  if  a piece of prepared sponge
would not answer  still better.   This substance, by imbibing the li-
quid at the  bottom  of the wound, would evidently make compression
outwardly in the most advantageous manner;  but it would also pos-
sess the inconvenience of being liable  to be broken when it was
found necessary to withdraw it.  If the blood, instead  of escaping
outwardly, should have accumulated in  the interior, it would be diffi-
cult to recognize it before death.  In supposing moreover the con-
trary case, the surgeon would not be benefitted by it.  What  could
he do under such circumstances, and where could he go  to  seek for
the deep-seated vessel which furnishes the hemorrhage ?  We must
not moreover allow ourselves to be  imposed  upon by appearances.
We sometimes meet with, upon the surface of serous membranes, a
sanguineous exhalation so abundant as to communicate to the water
drawn from a dropsical patient, the dark color of venous  blood ; so
much so that at first sight we might be induced to believe that it was
blood instead of serosity which was running from the wound we had
made.   A striking example of this occurred in an adult affected with
hydrothorax at the hospital of St. Antoine, in the wards of M. Rayer,
while I had charge of the surgical department in this establishment,
and there is no doubt that the same phenomena might take  place in
the peritoneal cavity.   The hemorrhage mentioned by M. S. Cooper
as resulting from a puncture upon the median line, might well belong
to this  description.  Upon the supposition that the one which was 
206
NEW ELEMENTS OF OPERATIVE SURGERY.
noticed at LaCharite, in 1824, was not produced by a pure and sim-
ple wound of the epigastric artery, it might also be explained in the
manner I have mentioned much better than by the alleged  lesion of
a mesenteric vessel.  M. Piegdagnel however relate^ an instance of
a copious effusion of blood, caused, as he  believes, by a puncture of
an artery of the epiploon.

          Article  II.—Humoral  Tumors of the  Liver.

  Abscesses, hydatid cvsts and encysted dropsy of the liver, have
been for  a  long time, and  are  still regarded by many persons as
placed beyond  the reach of all surgical resources.   The difficulty of
recognizing them with certainty during life ; the danger of producing
an effusion into the peritoneal cavity, and allowing  the action of the
air  on the walls of the  collection, are the reasons why an artificial
opening  has been  generally proscribed.   There are, however, re-
lated instances of cures obtained  by means of a puncture with the
trochar, or by means  of an opening made with caustic  potash.  On
the other  hand, the  mode by incision having been the subject  of spe-
cial  researches, and  M. Recamier having succeeded  in obtaining
very fortunate results by combining those different resources, I  have
thought it proper to treat of them in this place in a separate  article.
Puncture alone would be insufficient should the cyst contain anything
else  than limpid serosity.  Moreover, it would cause the effusion  of
a certain quantity of liquid  into the belly, should there not have been
established protecting adhesions around the part  that is perforated.
The employment of the bistoury would  be still  much more apt to
give rise  to the apprehension  of this  accident:  it cannot be appli-
cable except in cases where the diagnosis leaves no room to doubt
the  nature and anatomical relations of the cyst.  Caustics, by acting
too  slowly, incur the risk, it is said, of general  peritonitis, in  conse-
quence of the local  inflammation which is produced by their applica-
tion.  A young lady, however,  whom MM. C.  Broussais, Sedillot
and  myself treated in 1838, by  means of the free application of po-
tassa, was perfectly re-established.  In the process of M. Recamier,
potash is  first applied upon several  points  that are nearest  to the
morbid  projection, in  order that by their reunion they may  make a
large eschar, which is laid open at the expiration of a few days by
means of the cutting instrument.  Another portion of caustic  is then
applied  to the  bottom of the wound, and  which is  destined to act
much rather in  its depth  than in its breadth.  Repeated in this man-
ner in succession, the cauterization is certain to promote the adhesion
of the hepatic portion of the peritoneum with that of the abdominal
walls, and enables  us to plunge into  the cyst either the trochar or
the  bistoury, as soon as the finger  clearly recognizes the fluctuation
underneath the incised eschar.  After having extracted all the liquid,
M. Recamier, imitating the practice  of M. Billerey for empyema,
substitutes for it medicated  injections, which he renews every day,
and which he retains  in the morbid cavity, in the intervals between
the  dressings, by shutting up  the  wound with  a pledget of  lint  or
sponge.   By this means  the action of the  air is prevented, the pus,
diluted as soon  as it is produced, cannot stagnate or pass into a pu- 
            CYSTS AND TUMORS OF THE  OVARIUM, ETC.          207

trid state in the interior of the abscess, and the sac gradually shrink-
ing upon itself, ultimately becomes transformed throughout its wThole
extent into  a simple fistula, whijch,  in its turn, may be healed up.
Can it be necessary to add, that the same treatment is applicable to
tumors in the gall bladder, as soon as they are placed under the con-
ditions laid  down and so well described  by  J. L. Petit ?  . To eluci-
date the diagnostic in all the affections under consideration, we are
frequently obliged to make an explorative puncture by  means of a
small trochar or cataract needle, in  the  same way, for example, as
when we wish  to distinguish with certainty between an  aneurism
and an abscess.   M. Recamier justly remarks that, in this case, the
instrument  should be very  delicate,  and suddenly withdrawn from
the tissues.   Unless  this were done  it might make a wound which
would give ready egress to the liquid, in such manner as to cause it
to be effused into the abdomen or in the surrounding organic tissues.
Another mode of opening into morbid collections of the  liver or ab-
domen, and which was proposed in 1827  by M. Graves, (Arch. Gen.
de Med., t. XVIII., p. 295,) is worthy of being placed alongside  of
the preceding.   This  surgeon employs  the  bistoury only.  Aftei
having freely incised all the tissues, as far down  as to within one or
two lines of the  abscess, he stops and fills the wound with  lint, and
waits until the tumor shall open of itself, at the bottom of the wound,
during a paroxysm  of coughing, &c.  M. Begin (Journ.  Hebdom.,
1830, t. I., p. 417,)  has  since proposed,  for  all purulent abdominal
collections, that we should  proceed in this manner, layer  by layer,
down to the peritoneum, and stop there should there be no adhesion,
but, in the contrary  case, to penetrate into the cyst.  Should the tu-
mor be still  free, the  wound of the peritoneum, which it immediately
tends  to  fill up,  speedily agglutinates with its anterior surface, and
three or four days after we  may plunge in the instrument in  this part
without any danger  to be apprehended from effusion into the belly.
Facts, sufficiently conclusive, have been  related  in England and in
France, in favor of this ingenious method, and I have had recourse
myself to it  in three instances with advantage.

 Article  III.—Cysts and Tumors of  the  Ovarium and  of the
                         Lower Belly.

  The ovarium is frequently the seat  of a degenerescence, which has
been pointed  out by authors of every epoch, but for which no one
scarcely proposed to procure relief by means of a  cutting instru-
ment until about a century  since.

                      § I.—Appreciation.

  Le  Dran,  Housson and  Garengeot had  already  remarked that
puncture scarcely ever succeeds  in  this affection, while it  is some-
times cured  by freely incising the  cyst.   The patient of M. Holscher
(Arch. Gen. de Med., 1838)  was cured  after puncture,  by  means
of an injection of two litres of wine.  Morand  maintains that ex-
tirpation  of the  diseased organ  should be performed  at the very
first. 
208
NEW ELBMENTS OF OPERATIVE SURGERY.
  A. Successful Results.—Facts communicated  by Delaporte and
Lieutaud we're adduced  in favor of this operation, the process of
which had already been given by Thumin, and which  two English
physicians, Power and Darwin, hastened to advocate with zeal ; but
in spite of the efforts of M. Ischier, (These de Montpelier, 1807,) the
successful result attained bv  Laumonier, the  cure  of Mdme. de
Choiseul, and the similar result related by M.  Kapser,  the proposi-
tion  of Morand. nevertheless, remained  without any  adoption  in
practice,  until M. Lizars (Bull, de Fir., t. IV.,  p. 144.) undertook to
recall attention to it in 1825, while on their  part MM. McDowell,
Nathan and  Alban  Smith,  (Journ. des Prog., t. V., p.  273.) made
trial  of it in  America,  and MM. Dieffenbach, Chrysmer  (Bull, do
Firr., t. XVIII., p. 86,) and Martini sought  to  render it popular  in
Germany.  At the present day the operation has been performed a
sufficient number of times to enable us to appreciate the extirpation
of the ovaries at its just value.  Leaving  aside the operation as
formerly  performed by Lemman, the  one published  by M. Lafflise
of Nantes, and another which  belongs to  Delpech, I  will confine
myself to an enumeration of the most important cases.   The tumor
removed  by M.  McDowell from Mrs. Crawford in  1809, weighed
15 pounds, and the cure was completed on the 35th day.   In another
patient, M. McDowell finding both ovaries  affected, made his inci-
sion  upon each ; a quantity of blood  was effused into the belly, but
the  operation, nevertheless, was  attended with entire success.  In
1816 he  removed  an  ovary  from a  negress,  which  weighed six
pounds, but which was  also followed by a perfect cure.   Two other
women whom he treated  in the same manner were not so fortunate;
one remained in feeble  health and  the other died.   Dzondi in one
instance  succeeded by means of an  incision,  the  employment  of
tents, and afterwards by extirpating  the  mortified cyst.  Pure and
simple extirpation performed in a case in  1821 by M. Smith, was
not followed by any accident.   The tumor removed by M. Lizars on
the 27th  of February,  1825,  was as  large as  a foetus at  the full
term.  It became necessary to prolong the wound of  the belly from
the xiphoid appendix down to the pubis.  The other ovary was also
affected, but  the  patient, who  was 36 years  of age, nevertheless
ultimately recovered.   Dr. Chrysmer, sent for to a woman 38  years
of age, had every reason to be satisfied with his  resolution to perform
the operation : at the expiration of six weeks  the  patient was in a
condition to  return  home.  M. A. Smith operating on the 6th May,
1822, on  a young lady, extracted the cyst  after having taken  six
pints of liquid from it, and after having strangulated it at its base by
means of a strong ligature, which came away at the expiration of a
month and a half.  In 1824 this  lady was still in the enjoyment of
the  most perfect health.  M. Jeaffreson (British Annals of  Med.,
vol. II., p. 140,) incised the cyst, extracted twelve pounds of serum,
drew it outwards and extirpated it, and also cured his patient.  M.
King (Ibid., vol. II., p.  141,) obtained a similar  successful result.  In
the  case  of M. Weitenkampff, (Encycl. des Sc Med., 1836, p. 342.)
a spontaneous opening in a similar  cyst into  the vagina was also
succeeded by a cure.  M. Quittenbaum, (Ibid., p. 306,) in extirpating
the tumor, after having extracted from it 20 or 30 pounds of liquid 
            CYSTS AND TUMORS OF  THE OVARIUM, ETC.         209

by puncture, even alleges that he effected a cure of his patient in the
space of ten days!  After numerous punctures,  M.  Rogers (New
York Med. and Phys.  Journ., 1830, p. 285,) extirpated the cyst and
succeeded.  The same result followed in the case of M. Ehrharstein,
(Arch.  Gen. de Med., t. I., p. 427 ;  Med-Chir. Rev., July, 1833, p.
242,) who removed in  this manner a degenerate  tumor of the  ova-
rium, and in that of M. Ritter, (Tahere  These, No. 85, Paris, 1839,)
who was no less fortunate.
   B.  To these cases of actual extirpation, followed by a successful
result, we have to add others  in  which the tumor was not entirely
removed, and where the operation was not completed in the manner
proposed before commencing  it.  It was in this  way for example,
that M.  Lizars, finding  a simple adherent mass in front of the sacro-
iliac-symphisis, instead  of  an enormous  cyst  as  he had at first sup-
posed it to be, deemed  it proper to restrict himself to the first stage
of the operation, that is,  to the incision of the parietes of the abdo-
men ; immediately closing up the wound, he considered himself suf-
ficiently fortunate in saving the life of his patient.  In another case,
M. Granville, (Journ.  des  Prog., t. I., p. 274,) perceiving that the
cyst could not be detached from the surrounding parts without  diffi-
culty, confined himself  to laying it open freely, and carefully  empty-
ing it.   By this course he  obtained complete success.  M. Dieffen-
bach, alarmed by the size  of the base of the tumor, and of the ves-
sels it contained, and seeing moreover that blood only issued from a
puncture made in its centre, did  not venture to remove it, and im-
mediately united the wound, when the patient also recovered.
   M. Galenzowski,  (Journ.  des Progr., t. XVIII., p. 222,) also per-
ceiving  that the tumor was too adherent to be removed, emptied it by
a large opening, broke  up its different cells, traversed its deep-seated
wall with a thread, drew it towards the wound in the abdomen to
prevent all effusion into the peritoneum, closed up in the best manner
he could the incision in the abdominal parietes, and obtained in this
manner a perfect cure in  the  space of a few weeks.  M. Mussey,
(Gaz. Med. de Paris, 1838, p. 393,) who after having freely incised the
walls of the abdomen, confined himself to the puncture of the cyst,
and  afterwards the  employment of a meche, also succeeded.   M.
King, (Press. Aled., t.  I., p. 634,)  who, deterred  by the fainting of
the woman in one case, and from  not finding in another any tumor
in the belly when he had introduced his  hand there,  closed up the
wound by suture and had no serious accidents follow !  M. Dohlhoff,
(L'Experience, t.  I., p.  634,) after having made  an incision  of five
inches, and finding no description of tumor, also closed up the  wound
and saved his patient!
   C.  Failures.—Other trials have  been less fortunate.  A woman
40 years of age, operated upon on the 20th September, 1822. by M.
McDowell, died on the  morning of the 24th.  M. A. Smith, deterred
by the intimate and very extensive adhesions of a tumor of the  ova-
rium, in a patient  who  herself  had punctured it more than 80 times,
restricted  himself to the incision  of the walls" of the belly, and did
not dare to terminate  his operation.  He had the misfortune, how-
ever, to see this lady perish on the 42nd day.  The patient operated
upon bv M. Lizars on the 22nd March, 1825, died on the second day
   vol. in.                     27 
210
NEW ELEMENTS  OF OPERATIVE SURGERY.
 after.   The  one which was operated upon by MM. Hopfer, (Bull.
 de Fer., t. XVIII., p. 86,) and Chrysmer,  survived  only  36 hours.
 Another operated upon by M. Chrysmer himself was not less unfor-
 tunate.  The young girl whose case is given by M. Martini, also died
 at  the  expiration of 36 hours.   The  patient operated upon by M.
 Warren, died at the end of  three hours, and  M. Dohlhoff, (L Expe-
 rience, t. I., p. 625, 626,) who. though the special pupil of M. Dzondi,
 never heard  him speak of the successful results that M. Lizars im-
 putes to him, speaks:  1st, of a woman operated upon by him, and
 who died of  peritonitis  in 36 hours, (Ibid., p. 630 ;) 2nd, of a female
 operated upon by M.  Giath, (Ibid., p. 631,) who died  from hemor-
 rhage  at the expiration of sixteen hours ;  3rd, of another in whom
 he opened the belly, and who had the epiploon cribbled with tumors,
 and who died eight hours  afterwards, (Ibid., p. 633,) without of
 course the operation being carried any farther.  M. Key, (The Lan-
 cet, 1828, vol. I.,) in a  case in which he employed  puncture and a
 tent, did not  succeed.    M. Kapser obtained only one  cure out of
 three cases.  A woman in  whom the cyst was of  the size of the
 uterus  in the  eighth month of pregnancy, and in which M. Recamier
 (Revue Med., January, 1839,) made a puncture in order to  introduce
a meche or seton from  above downwards  through  the vagina, also
died.   M. Marjolin, (Thaere These, No. 85, Paris, 1839,) who con-
fined himself to  an injection  of sweetened barley water, was no less
unfortunate.
  D. Real Value.—Extirpation of the ovarium, though dangerous, is
nevertheless a resource which requires examination.  The ovary is not
so indispensable  to the existence of life that a woman cannot be de-
prived of it  without  very  great danger.  The gelders  of beasts
remove them without any apprehension during the first weeks of the
life of the animal, in the  female of the hog, and I am enabled to assert
that in their hands this  operation  is scarcely ever  followed  by any
accidents.  Diemerbroeck relates, that according to Atheneus, Adra-
metes,  and  according   to Suidas, Gyges,  king  of  Lydia,  treated
the women in their kingdom  in this manner.  Alexander-ab-Alexan-
dro says the same of the Creophagi and the  Egyptians.   Wierus
states that a gelder  suspecting the chastity of his daughter,  opened
her belly, and drew the womb to the outside in order to excise the
two ovaries, and  that this cruel operation was followed with complete
success.  Franckenau,  Pott,  Lassus,  (The  Lancet, 1828,  vol. I., p.
878,) and M.  Deneux^  each relate  an instance of extirpation of the
ovary, which did not prevent the females from afterwards enjoying
excellent health.
  In conclusion, the operation is not in itself either delicate or diffi-
cult.  The occasions for performing it are unfortunately but too  fre-
quent.   The  diseases which  require it, if left to the resources of the
system, almost always  terminate  in death.   But also, in order that
there should be any chance for success, it is necessary that the tumor
should  be movable, that it should not adhere to the intestines, that it
 should  be susceptible of being detached with facility from all the ab-
dominal organs, that it should have a root or pedicle of small size, and
that it should not expose to the risk of wounding vessels of too large
a calibre.  It is necessary also, that it should be susceptible of being 
            CYSTS  AND TUMORS OF THE  OVARIUM, ETC.         211

recognized and distinguished  from every other disease, which is far
from being always an easy matter.  In the  beginning, how can we
avoid confounding it with some tumor or other attached to the uterus,
the iliac fossae, &c. ?  Moreover, who would/then dare to propose to
extirpate it?   At a later period, when it occupies a  large extent of
the abdomen, the new relations contracted by the organs which sur-
round it, and the almost inevitable adhesions of its periphery, would
render its dissection and ablation, if not impossible, at least exceeding-
ly dangerous.   Finally, though incurable in its nature, it  does not
generally cause death until after a long protracted period.  As a me-
dium term, its duration is usually prolonged, not to 12 years,  as M.
Corbin thinks, but 5 or 6 years in women who are affected with it.
Nevertheless, if as  happens often  in such cases, the  general health
has been preserved in a manner which  contrasts strongly with that
of the diseased condition of the abdomen ; if the issue of an  unctuous
or gelatinous liquid obtained  by means  of an explorative puncture,
demonstrates that the disease is situated in the ovarium ; and if the
tumor does not exceed the  size of the head of an adult, and the pa-
tient ardently  desires the operation, it ought  in  my opinion to be un-
dertaken.  Only that it remains to determine if the simple incision ac-
cording to the rules laid down in the preceding article, made trial of
by Portal and Denman, (whose cures however are doubted by M.
Key,) and by MM. Ray and  Ramsden, who have also, it is said, each
obtained a cure by  this mode, ought not to be preferred to  extirpa-
tion, properly so called.

                    § II.—Operative Process.

   The woman placed upon her back, with her lower extremities mo-
derately extended and  held by assistants,  should be adjusted in such
manner that the most prominent portion of the cyst presents itself to
the operator.  This last first makes, in a direction parallel to the axis
of the body, an incision from  four to six or  eight inches long upon
the most suitable part of the  abdomen, makes use of the forefinger
of his  left  hand to guide the bistoury,  as soon as the peritoneum is
opened, and then occupies himself with the tumor.  Should it be free
and movable, and easily isolated, and have  a narrow  pedicle, the
surgeon has nothing more to do than to tie a ligature firmly around
its root, and to excise it upon the outside of the constriction by means
of the bistoury or scissors.  Should the  adhesions which unite it to
the surrounding tissues be loose or easily destroyed, he detaches them
by means of a careful dissection, and proceeds in respect to the re-
mainder of the operation as in the other case.  Should it  prove to
be fungous, and  to have a large base and  blood-vessels of consider-
able size, it would be better not to meddle with  it and to close up
the wound immediately.  Should  its adhesions to the  wall of the
belly not admit of its removal, we should plunge the bistoury into it,
and lay it open  freely 'in such manner as to empty it entirely, and
that the cyst may afterwards  be gradually drawn into the wound of
the abdomen.   The position,  adhesive plasters or the suture will be
used according to the nature of the cases, to reunite the wound, which
moreover should be dressed, in the simplest manner possible.  When 
212
NEW ELEMENTS  OF OPERATIVE SURGERY.
the solution of continuity has been very extended, the intestines have
so great a tendency to escape externally, that the suture  then  be-
comes  almost indispensable.   The  same takes place nearly in  all
cases, where  in order to remove the  tumor, it has not been necessary
to lay it open, nor to occasion any very great destruction of parts in
the interior of the belly.  It  is directly the reverse when we have
only emptied the cyst, or have not had it in  our  power to extract all
that we wished to remove.  Upon the supposition that we purpose to
confine  ourselves  to  the incision, it would  be necessary to put our-
selves on  our guard  at  first, against effusion, and to encourage the
previous formation  of protecting adhesions, if they did not already
exist, between the morbid mass and the  parietes  of the  abdomen;
and finally, to act in the same manner as in the case of an  abdominal
abscess  or  hepatic collection.

       Article IV.—Tumors  of the Abdominal Parietes.

  M. MacFarlane, (Encyclog. de la Sc Med., 1836, p. 54,) who states
that he has removed with success an hydatid tumor in the iliac region,
was less fortunate in  two other cases.  Entering  through the punc-
ture into a cyst,  between the peritoneum  and the muscles,  death
took place on the fifth day.   Compelled to remove the ends of the
two last ribs with a  fibro-cartilaginous tumor  which had become
developed  between the muscles, he had the misfortune to lose this
patient  by peritonitis at the expiration of thirty-one hours.  In the
case cited by M. Basletta, (Bull, de Fer., t. X., p. 95,) the removal of
the cyst, containing a pulpy substance analogous to that of the testicle,
and which communicated with the peritoneum, was followed however
by the cure of the  patient.  It was the same with the cyst in the case
mentioned  by M. Dufau, and which burst during  an effort made by
the patient.  M. Monod has shown me a neuromatic or atheromatic
mass  of the  size of a large fist, which he had successfully removed
from between the abdominal muscles ; but I have mentioned, under the
chapter on tumors in general, and of tumors of the abdomen in par-
ticular, what  ought  to be the  special operative process in cases of
this kind.  The important indication is  to avoid the peritoneum.
Should it have become necessary to wound  this membrane, we must
be  guided  by the rules laid down for the operation for strangulated
umbilical hernia, the Cesarean operation, or that employed in cases
of cysts of the ovaria, &c.
  [Ovariotomy.—The  results of the latest  researches and examina-
tions of comparative statistical tables on this subject, as furnished  by
MM.  Jeaffreson,  (London Med. Gaz.,  October, 1844,) B. Phillips,
(London Medico-Chir. Trans., vol. XXVII., 1844.) Chereau, (Journ.
des Conn.  Mid.-Chir., Juin,  1844,)  F. Churchill, (Dublin Journal
and Archiv. Gen., 4e serie, t. V.) and Emiliani, (Giornali dei Pro-
gressi, January, 1845,) seem to admit of our establishing the follow-
ing conclusions, deducible  from about one hundred cases in  which
the operation has been performed, up to the present year, 1846, (see
Archiv. Gin. de Paris, Fevrier, 1846, 4e  serie, t. X., pp. 216—219.)
1. That the operation  is practicable, and even easy, in most instances.
2  That it  has received unmerited reproach, in consequence of enu- 
FI3TULAS  IN  THE STOMACH.
213
merating under its failures those cases which have been abandoned,
and in which  the  operation has been left unfinished, from the opera-
tor having  ascertained that his diagnosis was false and the adhesions
too extensive,  (see Jeaffreson, supra cit.)  3. That the most favorable
indication for it is  the existence of liquid, and especially monolocular
tumors, in which the whole contained fluid may be readily evacuated
by paracentesis as often  as  it forms,  but  which therefore, for  the
same reason, are those in which it is least called for.   The next most
favorable, and where, however, it is at the same time most required,
are the multilocular liquid tumors, because here the puncture can
have but little, at least only a partial and temporary effect.  Again,
it  is in a great measure contra-indicated, and ought to be forbidden,
as we think,  in solid  or  sarcomatous or fibro-cartilaginous  ovaric
tumors, from  the  very extensive nature of their adhesions.   Nor do
we except, with  Dr. Jeaffreson, from  this remark the cases where
such tumors lead to consecutive  ascites, threatening a fatal issue.
4. The larger the incision, the less the chances of cure; and  the
smaller the incision, the more the prospect of a successful issue, even
though to facilitate this last, the cyst has to be punctured before it is
extracted.   5.  The proportion of deaths is in the ratio of 49 out of
every  100  cases operated  upon, i. e. 49 deaths and 51 cures, which
is  a relative mortality not much  greater (Arch. Gin.,  ibid., loc. cit.,
t. X., p. 219,) than that of  amputation of the thigh.  But we are to
deduct in part  from this estimate,  and in favor of the operation, the
fact, that in 18 cases out of the 100,  the operation had to be aban-
doned, which of course, in some degree, augmented to the same ex-
tent the chances of a fatal issue ; while, on the other hand, there was
a false diagnosis  in 7 out of the same 100 cases.  6.  That so far
from adopting  the  precept of Dr. Jeaffreson, that the operation may
be justifiable where the size of the tumor gives rise to great annoy-
ance or inconveniences, or  to such  functional derangements as threa-
ten a fatal issue, we do not think that it would  even then be admissi-
ble, except under  very peculiar and  very unusual circumstances.
7.  That, on the contrary, we  coincide  with  the reviewers  of the
Archives Generates, (t. X., Ioc. cit.,  p. 219,) in language which seems
also  wholly congenial with the  text  of our own author:  that  the
extirpation of ovarian cysts, though it cannot be absolutely rejected,
can be had recourse to only in cases that are wholly exceptional and
excessively rare, and where every  other known  therapeutic means
has been exhausted.   T.]

 Article V.—Fistulas in the Stomach,  (Fistules Stomacales.)

  Having elsewhere spoken of foreign bodies  in  the abdomen, and
having yet  to speak of gastrotomy and stercoral and urinary fistulas
in  the chapters which are to follow, I have but a few words to say in
this place on the subject of stomachic,  biliary  or renal fistulas.   An
instance of stomachic fistula has been published by M. Stokes. (Arch.
Gen. de Med.,  2e  serie, t. VI., p. 430,)  and M. Beaumont (Journ. de
Prog., t. XII., p. 254,) has related another.  M. Lowel (Bull, de Fer.,
t. VI., p. 157,)  states that he saw a similar result in one of his patients,
produced by a  gun-shot wound, and M. Cook, (Arch. Gen. de Med., 
214
NEW ELEMENTS OF OPERATIVE SURGERY.
2e serie, t. VI., p. 430,)  alleges that he cured one in fifteen days by
means of compression;  but I am not aware, up to the present time,
that the slightest operation has been attempted for this description of
fistulas,  which,  moreover, are quite  uncommon.  We might, how-
ever, I think, have recourse, with some prospect of success, either to
the simple suture or to one of the modes of anaplasty described else-
where,  and which I shall recur to in treating of artificial anus.   As
to biliary fistulas, an instance of which has been given  by M. Civiale,
(Gaz. Med., 1832, p. 130,) and renal fistulas, of which I  have met with
three examples, thev are produced either by calculi,  or some other
lesion either of the gall-bladder, or of kidney or its pelvis (bassinet,)
which must first be  relieved before we proceed to their treatment.
PART  FIFTH.

     HERNIA.
                         CHAPTER I.

                     HERNIA IN GENERAL.

               Article  I.—Anatomical Remarks.

  A hernia, of whatever description it may be, presents two points
for consideration,—its envelopes, and the  viscera which constitute it.

                         § I.—Viscera.
  There is no organ in the belly which may not, under certain cir-
cumstances, form  a hernia.  They  are  not all of them, however,
equally liable  to strangulation.  Thus the  bladder, ovaria, uterus,
spleen, and liver, have been seen either together or  separately in a
hernial tumor.  But it can scarcely be  conceived that these various
organs are of a nature to undergo strangulation.   An intestine, on the
contrary, as soon as its calibre is interrupted in any point whatever,
must necessarily give rise to many serious symptoms.  The constric-
tion of the epiploon does  not, however, admit so ready an explana-
tion of these phenomena ; but whether this  depends upon tractions
made on the stomach and large intestine, or upon a sympathetic re-
action transmitted through the branches  of the trisplanchnic nerve,
experience has shown that they may be developed  under such cir-
cumstances, and that this fact must be admitted.

                        § II.—Envelopes.
  The coverings in every hernia comprise as their essential elements,
the integuments, the sac, and the intermediate layers.  The skin presents
nothing remarkable, except in relation to its different conditions of
thickness, density, and adhesions.   It is entirely different with the sac.
  A.  Sac.—The name of sac is given to that portion of the perito- 
anatomical remarks.
215
neum, which is protruded by the viscera outside of the belly, and
which forms the first covering of the hernia.   The ancients had very
confused ideas upon this subject.  They supposed that the descents or
hargnes, (hernias,) which they also called on that  account ruptures
or rompures, were produced by  means of a  laceration of the perito-
neum.  At the time of Dionis, it is true, this error no longer existed,
and the existence of the  hernial  sac was already admitted in the ma-
jority of cases;  but it was not until the  time of Mauchart and Ar-
naud, about  the middle of the last century, in fact until  the time of
the Academy of Surgery, that the  sac was considered an integral
part of every description of hernia, so that at  the present  day its
presence is  always deemed essential.
   I. I am in an error, for the moderns acknowledge that hernias re-
sulting  from wounds penetrating  into the  abdomen,  the  Cesarean  r
operation, a ligature upon the iliac arteries,  and  gastrotomy, may in
general be destitute of this sac.   Nor does  a hernial sac exist when
the bladder is displaced  at its anterior surface, or the caecum upon
the part at which it is adherent.  This is a fact which M. Colson of
Beauvais has demonstrated in opposition to the opinion of Scarpa,
who entered into a long  discussion to prove the  contrary.  We will
remark, however, that under this last point of view, it  is rather a
dispute about words, than  a  real difference of opinion.   Scarpa, in
maintaining that csecal and vesical hernias possess a sac, only wished
to say in fact, that a greater or less extent of the displaced organ re-
mains free in the tuuaor,  and  that a prolongation of the  peritoneum
is found there  as well as in  ordinary hernia.  But M. Colson does
not pretend to deny  this arrangement;  he  alleges only, that inas-
much as the hernia  is adherent in the  greatest extent  of its surface,
we cannot give the name of sac to the portion of peritoneum which
covers the remainder  of it.   Some persons, on the other hand, con-
sider that hernias which  are caused by traumatic  lesions of the ab-
domen,  have a sac as well as the others, unless they are not protruded
before the complete cicatrization of the  wound  of the  peritoneum.
It is a question, however, which  does not appear  to have been con-
sidered  in a correct point of view.
   II.  When & perforating wound closes up and is cured, there is or-
dinarily produced by it a cicatrix, which has less thickness, and is
less resisting than the natural walls of the abdomen.   The explana
tion of this  is not that the two lips of the  peritoneum are not re-
united, but because, in place of muscles and  aponeuroses, there exists
in this part  only a fibro-cellular  tissue of new formation.   If then a
hernia should  be formed  here, whether it protrudes the cicatrix be-
fore it, or does nothing more than to displace it, in order to arrive ex-
ternally, we cannot  perceive how it can fail  of being surrounded on
every side by the peritoneum,  and of possessing a true sac.  But this
cicatrix may to some extent  remain independent  of the serous ab-
dominal layer, as it may happen that  the peritoneum  may have ad-
hered so closely to the borders  of the wound, which  allows egress
to the viscera, that the hernia shall have no sac.
  III. What takes place  in this case is also noticed at  the umbilicus.
I  am perfectly satisfied, from dissections, that  umbilical hernias (exom-
phales) do not usually have an internal tunic  which can be separated 
 216          NEW ELEMENTS OF  OPERATIVE SURGERY.

 from the other envelopes.   The smooth layer (la couche lisse) which
 has been taken for this, is intimately united with the external tissues,
 and has been developed by dilatation, and not by displacement of or
 traction upon the peritoneum.  These facts authorize me to establish:
 1st, either a true sac by transposition of the peritoneum; 2d, a false
 sac  by simple distension of this  membrane or of any other descrip-
 tion of cellular tissue ;  3d, an incomplete sac in  vesical, and in caecal
 and hernias, &c.; that is to say, that the hernial pouch is lined through-
 out with a true serous  membrane, in the vast  majority of cases, in
 some others but partially only, and that in a very small number what
 we see in its interior is only a simple surface in  place of a membrane.
  IV.  The form and size of the sac vary in an almost infinite degree.
 Hemispherical, globular, pyriform, bosselated, conical,  cylindrical,
 bisacculated, with a duplicate, triplicate, or quadruple neck, &c, it
 may scarcely exceed the size of a small nut, or be as large as that of
 the head  of an adult.  Its internal  surface, which  is smooth  and
 moist,  does not differ from that of serous membranes in general.   Its
 external surface requires a little more attention.   In the true sac  it is
 lined with a cellular layer, which necessarily plays an important  part
 in the  history of hernias.   Being a portion of the  internal fascia
 superficialis or of the fascia propria of the peritoneum, this layer
 exists everywhere, but under different conditions of laxity, thickness
 and  adhesions, which are exceedingly dissimilar upon various points
 of the  abdominal cavity.  It is in this that we meet with the vessels
 which  are generally referred to the peritoneum, tmd  it is  this mem-
 brane which, by its induration or gradual thickening, produces what
 is called the epaississement of the sac, and which, after having under-
gone a filamentous  or semi-fibrous transformation, gives rise, when
it is torn, to the bosselated  or irregular appearance presented upon
 the external surface of certain hernias, and it is this membrane  also
 which  may be the seat of inflammations,  suppurations or  morbid
 alterations of every kind.  From this in  fine come the great majority
 of vessels which  ultimately terminate beneath  the skin after having
 traversed  the muscles and aponeuroses, and it is this membrane upon
 which  are found those small adipose masses which gradually escaping
 through the vascular orifices of the fibrous or muscular layers of the
 walls of the abdomen, ultimately, in certain cases, produce a projec-
 tion under the integuments and lead to the erroneous supposition of the
 existence of hernias, properly so called.  Around a false sac this layer
 intimately blended  with the surrounding lamella?,  distinguishes  it
 from the preceding, and is  so constituted that in  place of a membrane
 which  may be isolated, it  presents only a surface wholly incapable
 of being detached.  The name of  neck which is given to the portion
 of sac which  is confined  in the  hernial  opening, might  be advan-
 tageously replaced  by that of root; for the first involves the idea of
 a strangulation, which is far from  always existing, while the second,
 which  is equivalent to the word origin, would  in all cases precisely
 express the thing intended.  The  neck  of the sac then, and  I speak
 of the  true sac, and which is generally  narrower than the body and
 bottom of this pouch, is quite frequently folded  or gathered up like  a
 purse in the ring which encloses it.  Should the hernia be ancient or
 the folds have  remained a long time in contact, it is readily conceived 
ANATOMICAL REMARKS.
217
that they might become agglutinated and impart to the neck under
consideration, a considerable degree of thickness and resisting force.
  V.  The existence of several necks in one hernia, which had already
been sufficiently well  explained by Arnaud. and afterwards by Pel-
letan and Scarpa, is no longer a matter of obscurity or surprise since
the labors of M. J. Cloquet.   Suppose  that a hernia,  after having
been a-long time reduced, should  afterwards reappear, and that the
neck of the first sac being too narrow to give passage to the viscera,
shall have been protruded by them at the same time that they draw
down  another portion of peritoneum and give rise  to the formation
of a new neck; should the same thing happen a second,  third or
fourth time, we shall  have produced a sac in the shape of a chaplet
with numerous necks.  When the first adheres'strongly by a portion
of its periphery to the neighboring tissues, it is possible that  the other
may only cause that to deviate, in place of forcing it to descend be-
fore it. In this  double sac (bissac) the two  pouches are  in front or
by the side of, and not  below each other. The production of such necks
is also possible where the hernia  has not been  reduced.  This then
constitutes a new protrusion, which is situated above the ancient one.
   VI. The  adhesion  of a cord or of a portion of the epiploon to the
bottom of the primitive sac, is one of the  most favorable circum-
stances for the  formation of a second neck.   Pelletan  mentions a
case in which the epiploon traversed in this manner  three contracted
passages,  in order to  fix itself  to the  bottom of  the  lower sac.
I have met with an instance  in every respect similar,  another  in
which the upper sac  also contained a noose of the  intestine, and in
1832  another still at La Pitie, which scarcely differed from  the first.
As to  the numerous necks of bosselated sacs,  they are formed  in
a manner  altogether  different.  These latter are simple hernias of
the sac, through lacerations of the fascia propria, or  of any other
fibrous layer which should have  taken its place.  The sac, instead
of necks, may be divided by actual septa and  form one or more in-
dependent  cysts below that portion which  continues to retain the
Viscera.  A  striking  example  of this I saw  in the patient  operated
upon by the process of M. Belmas.
   B.  Aponeuroses.—The tissues which separate the sac  from the
cutaneous layer necessarily vary according to the seat of the hernia,
and could not be studied with advantage except in each particular
hernia. I have therefore no  occasion to speak at the present time of
any  other  than  the common  cellular tissue and the superficial or
sub-cutaneous fascia.  When there are neither aponeuroses nor
muscles interposed, the fascia propria and  the fascia suphficialis
ultimately become blended in the thickness of the  hernial pouch ;
that is to say, that we can no  longer  distinguish any separation be-
tween the cellular lining  of  the skin and that of the peritoneum.
   C.  Hernial Openings.—The openings which  allow of the  forma-
tion  of abdominal, hernias are of  various kinds.  Some which ar6
accidental  lacerations, as occurs  in persons  in  whom  the  belly has
been  excessively distended  by  pregnancy, ascites or  any  tumor
whatever, &c, rarely give rise to strangulation.  The same remark
is applicable, in a  great extent, to  those which  result  from a pene-
trating wound of the abdomen.
   vol. in.                      28 
 218          NEW ELEMENTS OF  OPERATIVE SURGERY.

   There are others also which do not require any farther considera-
 tion.  The orifices which are here and there found upon the differ-
 ent  fibrous  layers of the oblique or transverse  muscles for the pas-
 sage of  vessels of the third order are of this description, and present
 moreover this remarkable feature, that the masses or adipose tumors
 whose pedicle they embrace, and which augment in size under the skin
 and  in the other direction are attached to  the peritoneum, may-dilate
 these openings and by degrees  draw a portion of the peritoneum
 into them in the form  of a sac or finger  of a  glove, in which the
 intestine in  its turn may ultimately become lodged or even strangu-
 lated, and  thus constitute a description  of hernia which is very em-
 barrassing to the practitioner who shall not  have been aware of its
 possibility.
   Those which it remains for us to speak of are arranged under two
 orders :  these are either simple  openings or rings, or passages of
 greater or less length and obliquity, and very generally known at the
 present day under the name of canals.   At the umbilicus, for exam-
 ple,  the opening is always annular, while at the fold of the groin it is
 generally canaliculated.
   I.  Rings.—The first species is  not met with except upon those
 points of the abdomen where the aponeuroses  and muscles do not
 form distinct layers, as at  the  linea alba, upon the  side, and at the
 vagina, rectum, &c.   From these parts, in fact, being incapable of
 becoming separated,  and admitting only of an opening for  the pas-
 sage of the viscera, the hernia arrives  under the skin immediately
 after having passed through them, and escapes in reality only through
 a simple circle before it is formed.
   II. Canals.—The second kind of hernial opening  is more compli-
 cated.  Its internal and its external extremity represent two distinct
 circles or two rings, which are sometimes separated at a considerable
 distance  from each other.  It is found only at those parts where the
 different layers of the abdominal parietes are naturally liable to be-
 come separated.  In the normal state it is usually occupied by vas-
 cular, nervous, or any other description of cords.  Its track, which
 may be allowed to have walls, is caused  by its two orifices being
 kept more or less widened by the muscles  or other tissues, and by its
 two  rings belonging to two different descriptions of aponeurosis.  If
 its internal and external openings are  exactly opposite to each other,
 the canal is  straight or perpendicular.   On the contrary, it is  oblique
 when they are situated at an unequal  distance from the median line.
 It  is to be added, however, that hernias, provided they have existed
 ever so little time, have a tendency to obliterate the  obliquity and
 canaliculated form of  the openings under consideration, and to trans-
 form them all into simple rings by a process which is easily explained.
 The  deep-seated and the superficial aponeurosis being  pressed upon
in  an opposite direction by the portion of organs which has obtruded,
and by that which still has a tendency to make its escape, gradually
obliterate the interval which naturally separates  them, and  are ulti-
mately found in contact.  An oblique hernial canal,  taken in its en-
semble, is sufficiently well designated  by the  shape of an elongated
Z.   Now it is evident that  the viscera which occupy a canal of this
description, naturally tend constantly to straighten it  by their own 
RADICAL cure  of hernia.
219
  weight, and to bring its two openings in face of each other, and that
  afterwards they may, as in the preceding  case, conglomerate them
  into the condition of a ring, which is almost perpendicular.  A hernial
  opening, however, whether it be a circle or a canal, almost constantly
  flares open  in  the manner of a funnel in the direction towards the
  abdomen, more so in some persons and less  in others.  As on the
  other hand, the vessels which  are sometimes found in the neighbor-
  hood of the neck of the hernia are  usually situated in the substance
  of the fascia propria, that is to say between the peritoneum and deep-
  seated aponeurosis, it results from this, that they are generally found
  pushed back to the distance of at least two or three lines  from the
  fibrous border, which causes the  strangulation, and upon which we
  are  compelled to act with a bistoury in order to overcome  the  d6-
• bridement.

              Article  II.—Radical Cure  of Hernia.

    Whatever may  be the seat  of the hernia, it always  forms an in-
  firmity if not a disease sufficiently alarming to have urged persons at
  every epoch not only to seek a palliative for it, but also to effect its
  radical cure.   The singular idea which induced the ancients to rank
  it among immoral  diseases, a notion which  is still so prevalent that
  country people frequently struggle  in secret against the symptoms
  which it may give rise to before complaining of them to the physi-
  cian, constituted an illusion which charlatanism naturally converted
  to its advantage.   Hernia also has had, since the time of Hippocrates,
  Galen, and Celsus, as it also still  has at the present  day, pretended
  curers and hernial physicians who are exclusively occupied with the
  treatment of this disease.  It would  be unjust however to censure in-
  discriminately the  numerous trials that have been undertaken to ac-
  complish its radical cure, even since art has been in the possession
  of valuable means  for retaining it.   Laboring persons and workmen,
  who in general are most liable to it,  derive but little  advantage from
  palliative means.   The  most perfect bandages are far from procu-
  ring among them the beneficial results that are obtained from them
  in the elevated  classes of society.  The pelote almost always escapes
  from the abdominal ring at the expiration of a few days or weeks,
  and  frequently the  entire truss  soon becomes  nothing more than a
  new source of dangers.

        § I.—Topical Applications,  Compression, Position.

   The emplastrum contra rupturam of the ancients, the brick cerate
  (cerat  de brique)  of J. Fabricius, the vinegar bags of Verduc, the
 sandal wood, tormentil, turpentine, and topical applications of Baby-
 net and Mile. Devaux, the famous remedy of the Prior  of Cabriere,
 a remedy which consisted of an astringent plaster applied over the
 hernia, and  muriatic acid given  internally; the cataplasm  of iron
 filings while diamond was administered internally, as recommended
 by A. Pare, after the advice of Guy de •Chauliac; the  decoction of
 dog-grass and spurge laurel, as used by Arnaud;  the carbonate of
 ammonia mentioned by M. Belmas, and a thousand other remedies 
220
new elements of operative surgery.
 of the same description, no longer find any advocates at the present
 day, except among quacks and old women.

                              §H.
  It is not altogether the same with compression, which has been suc-
 cessively lauded by Celsus, Theodorus, Aetius, G. de Salicet, Norsia,
 Blegny, Trecourt, J. L. Petit, Juville, &c.  Steadily persevered in
 and applied in a proper manner, it has frequently effected a radical
 cure, without being under the necessity for this result of carrying it
 so far as to produce the gangrene which has been recommended by
 some in Germany.  M. Fournier, M. Beaumont, and M. Duplat, have
 endeavored to bring  it into repute among practitioners, while main-
 taining that if it is combined with astringents, it may cure almost
 every description of hernia.

                             § III.

  M. Ravin also expresses a positive opinion, that topical astringents
 and compression may effect a radical cure of hernia at every period
 of life.  But with him these means are only secondaiy, the base of
 his method being the horizontal position of the patient during seve-
 ral entire months.  The observations of Riviere, F. de Hilden, Re-
 neaume, Arnaud, and Hey, and  the thesis of Rieck, show all the ad-
 vantage that may be derived from the treatment proposed by M.
 Ravin, and which it was said was in general use in Denmark at the
 time of Winslow; but besides the uncertainty of success, what pa-
 tient would consent to remain in his bed for six months or a year, for
 a tumor which  is so easily kept  up by means of a simple bandage ?
 The examination of these different remedies however, belonging to
 pathology properly so  called, I can speak of them only in a cursory
 manner, without pretending  to  appreciate their value or disadvan-
 tage.   They have moreover  attracted much attention since I called
 the attention of surgeons to them in the first edition of this work.

                  § IV.— Various Operations.

  The principal operations which have been employed in practice
 for the purpose of obtaining  a radical cure of hernia, are cauteriza-
 tion, the ligature, the suture, incision, excision, scarifications, dilata-
 tion, and the closing up of the ring.
  A.  Cauterization.—If all that were necessary to proscribe an ope-
 ration were to point out its dangers, and to demonstrate its inutility
 cauterization, which  was so frequently employed  at the time of Al
 bucasis, Roger, and Guy  de Chauliac, would not have been extolled
 by so many practitioners at  different epochs.   But by denying the
 successful results that it has in  reality procured, and by attaching
no importance  to advantages which it really possesses, its  antago-
nists in more than one instance have  advanced the cause of  those
 who endeavored to render this practice popular.   Avicenna speaks
 of surgeons who laid bare the hernia, raised up its internal envelope
 without opening it, and cauterized the ring to a great depth with  a 
radical cure  of hernia.
221
red hot iron.  Others, like Franco for example, laid open the  sac,
and confined themselves to touching its neck with a button cautery.
A number of chemical caustics were employed for  the  same pur-
pose.   The  oil  mentioned by G. Fabricius, the sulphuric acid of the
charlatan Littleton, and which  another charlatan succeeded in ren-
dering popular at Paris in the time of Arnaud, the muriate of anti-
mony, potash, the essence of euphorbium  and ranunculus, &c, have
been successively made use of.
  It was by the oil of vitriol that Maget,  sustained by Gauthier, and
who was soon after exposed by Bordenave in the Academy, obtained
in 1773 the pretended cures which induced him to request the patron-
age of the government, and with which he caused the  death of La
Condamine.   The potential cautery was applied upon the  skin in the
form of a line or on a circumscribed point near the neck of the hernia,
with the view of producing an eschar there, and of causing the sac
to suppurate after it had perforated  it.   It appears however that
Monro and  the naval surgeon mentioned by Sabatier, applied their
escharotic to the interior of the sac also.   Considered in this point of
view, cauterization embraces two methods which  are quite distinct,
one in which it is applied only to the hernial  coats, the other, on the
contrary, which attacks the orifice through which the  organs  have
been  protruded.  The  first is attended with the  inconvenience of
incurring the risk of not penetrating sufficiently deep, or if we do so,
of injuring some important organ;  the inflammation which it occa-
sions  may not  be limited to  the sac, but  extend to the peritoneum,
and in this manner cause the death of the patient.  The second also,
which does not entirely protect us  from this danger, possesses at
least  the advantage of enabling us to avoid with greater certainty
the viscera,  since the operator commences by laying  these bare and
pushing them back into the abdomen.  It must be  added that this
alone presents any chances of success.
   B.  Ligature.—The  mode of applying a ligature  around hernias,
which we are desirous  of curing radically, is far from  having been
always the  same  among all  authors.  Some  apply  it immediately
upon the sac, and others on the skin, without any previous incision.
Pare  mentions those who confined themselves  to a circular incision,
upon the bottom of which they applied the ligature.   At the time of
Paul, many practitioners  also had recourse to this furrow; but many
of these afterwards opened into the sac, in order to satisfy themselves
that no organ was included in the  ligature.  Guy de Chauliac says
that we must first lay bare the sac, in order to seize it and to stran-
gulate it with greater certainty at its root.  Among those who made
use of an indirect ligature, there are some who, like Thevenin, per-
forate the entire pouch with a double thread, and afterwards stran-
gulate its two halves separately.  J.  L. Petit, who has slightly modi-
tied this process, professes to  have derived great advantages from it.
Celsus speaks of other practitioners who  placed the  integuments be-
tween two  pieces of wood and compressed them in the same manner
as with a veterinary pincers,  until  they had become gangrened.   Fi-
nally, the most ancient process, and the one which  was  adopted by
 Saviard and Desault, consists in circularly constricting the neck of
 all the hernial envelopes, in such manner as  to effect its mortification 
 222          NEW ELEMENTS OF OPERATIVE SURGERY.

 in a greater or less length of time.   This method, which is less bar-
 barous and less formidable than cauterization, has certainly effected
 a  number of  cures.   If  Lassus had  understood better  the nature
 of the process, he would not  have called  in  question  those  cures
 which Bichat enumerates in the practice of Desault.  Every thing
 also goes to prove that  the medical societies of Lyon and  Paris
 would not have  so unequivocally  proscribed  it in 1812, when M.
 Martin addressed  his memoir to them  in order to revive this  prac-
 tice, if they had directed their attention to the nature of the inodular
 tissue, which is formed by the ulceration caused by the thread.  In-
 asmuch however as it cannot but be  painful, and incur  the risk of
 peritonitis, or include even some portions of the viscera, unless  it has
 been cautiously performed ; and as on the other hand umbilical her-
 nia in children, to which it is especially applicable, frequently  disap-
 pears without any application or under that of a simple bandage, this
 operation scarcely deserves to be rescued from the oblivion into which
 it has fallen, and the successful result obtained  by this means by M.
 Bal, does not enhance its value any more than those which are said
 to have been obtained by  it in experiments upon chickens.
   C. Suture.—The  suture, in  applying which they confined  them-
 selves to sewing up the sac, which had  been  previously incised or
 merely emptied, is in the first place  infinitely more dangerous  than
 the ligature in the manner it was applied by Desault, inasmuch as it
 sometimes requires a very tedious dissection before we can accom-
 plish it; in the second place, not necessarily  leading to the formation
 of an elastic cicatrix, since it is not attended with loss of substance,
 and has no other object in view than to obliterate the sac, it is  clear
 that it must be less efficacious in preventing the  return of the disease
 than the  first process.  Moreover it is  not susceptible  of  general ap-
 plication, as  it is calculated especially for inguinal hernia  in man, as
 well as  for  castration.  Consequently it is  unnecessary  for me to
 speak of it in this place.
   D. Incision.—Incision has been long  regarded as an excellent
 remedy for the radical cure of ruptures.   It was not scarcely until
 some time in the last century that  it  was abandoned by surgeons.
 All the tunics and the sac  itself were successively divided according
 to the same  rules  as for  strangulated  hernia.   The viscera having
 been reduced, they proceeded  to the  dressing, and the  wound was
 cicatrized in the same way as in the last case.   The obliteration of
 the sac was to be a necessary result of a process  like this, and the ope-
 rator hoped thereby to protect the patient from any return of a pro-
 trusion of the intestines from the abdomen.   It was soon perceived
 by practitioners that the question had not been examined in a correct
 point of view.  J. L. Petit, listening to the counsels of Arnaud, and
 contending against his own  convictions, deeply  regretted having had
recourse to this operation.  One of his  patients died on the fifth day ;
he was witness also to a similar fatal result, and it was not until after
having incurred the most serious dangers, that a third patient ope-
rated on was restored to health.  Acrel, Sharp, Richter, Abernethy,
 &c, in pointing out the same disastrous results,  have also shown that
incision in hernia is in itself much  more  formidable  than Lieutaud
 and Le  Blanc seemed to consider it. 
RADICAL CURE  OF HERNIA.
223
  E.  Excision.—If incision has had to be abandoned in practice, ex-
cision  has been proscribed for  much stronger reasons.  We could
not in fact dissect, isolate, and remove the sac, after having laid  it
open, as is recommended by Bertrandi, without augmenting to a still
greater degree the difficulties attending herniotomy.   By  confining
ourselves to excising opposite  the ring, a disc  including the entire
thickness of the envelopes of the tumor which has been previously
reduced,  as  is recommended  by  Lanfranc, we  might  also  give
rise to peritonitis, and  moreover  wound  the viscera,  should  they
be  ever  so slightly adherent to the interior  of the sac.   Excision
of the whole hernial pouch would, it is evident, expose to still greater
risks.   It is truly painful to read the details of operations of this de-
scription, in the works  of  Arnaud, Schmucker, and some other sur-
geons of  a more modern date.
  F.   Scarifications.—In place of excising  the  sac  after  having
laid it freely open, Le Blanc proposed to  effect the radical cure of
hernia by the dilatation  of the ring, which  had already been extolled
by  the ancients, but especially by Arnaud, to overcome the strangu-
lation.  The idea of scarifying the ring, which is attributed to Leon-
idas,  and which is distinctly mentioned by Verduc, Freytag, &c,  is
less extravagant, and Richter perhaps was not. conscious of  the full
value  of his remark, when he observed that those  small incisions in
such cases, greatly assist the adhesions which must follow the ope-
ration. The effusion of lymph which almost necessarily results from
them,  favors in fact the  prospect of all the tissues becoming blended
together at the opening  of the sac, and of closing up the ring effec-
tually.  If J. L. Petit and the surgeons mentioned by Heister, had
been acquainted with this fact, they doubtless would not have main-
tained that scarifications are better calculated to relax than  to con-
solidate the hernial canal  or  opening.  It is evidently  to a want of
this knowledge that we must impute the contempt of Lassus  for this
process, and the silence  which most modern authors have  shown in
regard to it.  The principal objection which may be brought  against
it, is that of exposing to the same dangers as incision, of which after
all it is nothing more than a simple modification.
  G.  Organic  Plugs.—The radical cure of hernia has always been
so ardently desired by patients,  that the necessity  of devising some
remedy has never ceased to be an object of extreme solicitude in the
minds  of surgeons, and that in our time many additional means have
been suggested for the same purpose.
  I. A plug of the epiploon.—When after the operation of strangu-
lated hernia, we are satisfied that the case is one  of entero-epiplocele,
we  may, after having reduced the*intestine by inserting the epiploon
into the rings, compel  it to  con'ract at that place adhesions which
will afterwards resist the reproduction of the rupture.  M.  Cooper
has  occasionally succeeded in this way, and  I am informed  by M. A.
H. Stevens of New York, that he has been no less fortunate.  I have
procured the same result in three patients, and M.  Goyrand has also
related some instances of the same kind.  However, besides that this
process does not always succeed, it possesses also  a double inconve-
nience : the epiploon, stretched like a net or in  the form of a bridle
from the umbilical region to the inguinal canal, predisposes to colics 
224
NEW ELEMENTS OF OPERATIVE SURGERY.
and  tractions  upon the stomach, and moreover to actual internal
strangulations; while,  in the second place, it scarcely appears to be
applicable except to cases of strangulated hernia.  I will neverthe
less add, that after the operation for every strangulated entero-epiploic
hernia, the epiploon, whether  we wish  it  or not, becomes attached
behind or  to the interior part of the  canal, in such manner as to form
the bridle which I have spoken of above.  It is a process  of plugging
therefore which is in some respects natural, and which  it is as well
to aid under the circumstances just  mentioned.
  II. Plugging with the testicle or  the sac—Moinichen  and Sculte-
tus speak  of a process which consisted of plugging up the ring  by
crowding  the testicle into it; but it  is  useless to speak of a suggestion
of this kind.  J. L. Petit, or Garengeot  rather, who dissected up the
sac,  formed it  into a peloton, and then pushed it back into the canal
in the manner  of a plug, as is still recommended by M. Steffen, (Fro-
riep, Notizen,  &c, b. 41, no. 3,) must have accomplished the same
result with less danger.
  III. A plug  of dissected integuments.—A lady operated upon suc-
cessfully for strangulated hernia, being much grieved  to find  her
malady return at the expiration of a few months, desired to be relieved
of it at every hazard.  It  was a crural hernia.  M. Jameson, after
having laid bare the ring, cut out at the expense of the neighboring
integuments a  lancet-shaped flap two inches long, ten lines in breadth,
and having its root towards the first wound,  then carefully dissected
it in order to reverse it and to introduce its floating portion into the
hernial opening, fixed  it in this position by reuniting the  solution of
continuity which he had just made, by means of some points of suture,
and supported  the whole by the aid  of an appropriate bandage. The
patient recovered perfectly, and there  is  every reason to believe that
the plug lodged in the crural  canal became engrafted  upon it.  At
first sight we see nothing but what is ingenious in this method, while
all its«details are plainly understood.  If, on  the one hand, it is more
complicated and painful, and  as dangerous  at least as incisions and
scarifications,  on  the  other it appears to  be of a nature calculated
to procure much more certain results,  inasmuch as we are sure by
this means of closing  up the passage  for the viscera.   Nevertheless
to appreciate  its value with a full  knowledge of the circumstances,
we require facts, but  science at present possesses only one.   I will
also remark that this fact does not possess  all the authenticity desira-
ble, and that  it is difficult to comprehend how  M.  Jameson, out of
respect  to the wishes of his patient, should  have consented to have
only the femme de chambre as an assistant and witness in an opera-
tion  of this description.   So iriuch  mystery,  in fact, is naturally
calculated to create doubts in the mind  of a person of the least sus-
picion.
  IV. Plug with the  invaginated  skin.—The  invagination of the
integuments in the manner performed by M. Gerdy, or by the modi-
fication  of M.  Leroy,  or that of M. Signorini, (Gaz. Mid.,  1827,
p. 236,) would  appear at  first sight t>  possess a greater degree ol
efficacy.   I have performed it  in  cne instance with  success.  M.
Gerdy appears to  have operated in  "his  manner upon abcut thirty
patients;  but  though many of them  appear to  have been cured,  it 
RADICAL CURE OF  HERNIA.
225
would be prudent, I think, to wait before adopting this method exclu-
sively.   In fact the plug which is fixed in this manner in the inguinal
canal, cannot contract any adhesions but such as are very feeble, and
everything unfortunately induces us to believe  that either a little
sooner or a little later the viscera will again crowd it to the outside
and reappear at the ring under the form of hernia.  Certain it is, that
a young man and two other patients, who were at first supposed to
have  been cured, and whom I have since seen, are at the present day
precisely in the same condition that they were before the operation.
I will add, that without being absolutely  dangerous or exposing to
any serious risk,  as has been supposed, of wounding the episgastric
artery, it may nevertheless bring on a phlegmonous  inflammation of
a grave  character in the iliac region, and even a fatal peritonitis.
  H.  Method  of M. Belmas.—ln  1829  M.  Belmas  projected a
method which appeared to  him  to be  at  the same time more easy
and certain and less dangerous than all the others.
  1.  First Process.—He recommends that we should introduce and
attach a small  pouch of goldbeater's skin to the upper part of  the
hernial sac.  The plastic matter soon spreads and penetrates into  the
texture of this foreign substance, and to some extent combines with
it.  The whole becomes  organized, contracts  adhesions  with  the
ring  or  neck of the  sac,  is transformed by  degrees  into  a solid
nucleus,  and ultimately establishes an almost insurmountable barrier
against the protrusion of the viscera.  Numerous experiments upon
dogs  corroborated the assertions of M. Belmas. It remained to apply
the process upon man, which was done for the first time  upon  the
Sieur Plessys, 54 years of  age, who  had been afflicted with a very
large sized inguinal entero-epiplocele  for the space of about 34 years.
The operation was attended with perfect success.   The author com-
municated his process to Dupuytren, urging him to make trial of it
upon  a boy aged 14 years, who  was  then at the Hotel Dieu, for a
congenital  hernia complicated with hydrocele.   Various circum-
stances rendered the operation long and  embarrassing.   Alarming
symptoms were  produced by it and caused much uneasiness during
the  space of about ten days.  The patient nevertheless was  gradually
restored,  and  about the termination of the  second month the hernia
as well as the hydrocele were found to  have been  radically cured.
A third trial  made by M. Belmas, assisted by M. Jaquemin, at  the
Madelonettes, on a girl of the town affected with syphilis and umbili-
cal  hernia, was not sufficiently complete  to enable us to deduce from
it any positive conclusions.   A solid and permanent cure,  neverthe-
less, was  effected by this attempt, in other respects so imperfect.  In
a fourth  patient, 57 years  of age, with  hydro-sarcocele, M.  Belmas
was desirous of ascertaining if his method would  succeed, at least in
closing up  the  ring and curing  the  hydrocele.   The  goldbeater's
skin had become consolidated at the upper part of the tunica vagina-
lis, which had become inflamed and  had to  be emptied of the sero-
purulent  matter with which  it had become  filled by the inflamma-
tion.  Finally, a fifth trial was made by myself, assisted by M. Bel-
mas, at La Pitie, in the month of November, 1830, upon  a man about
60 years of age, having two inguinal hernias for a long period of years,
and who, at his  entrance into the hospital, had exhibited some symp-
    vol. in.                    29 
226
NEW ELEMENTS OF OPERATIVE  SURGERY.
toms of strangulation, and who died in consequence of a gangrenous
ervsipelas.   The first of these cases is calculated to confirm all the
anticipations of M. Belmas;  the fourth, that of the hydro-sarcocele,
possesses, in my opinion, very little value in regard  to the principal
question, and scarcelv deserves to be noticed.  That of the public girl
proves nothing in itself either for or against the method.   The child
operated upon by Dupuytren appears to have been  seized with an
inflammation of the gastro-intestinal passages, and not with peritonitis.
In my own case symptoms of an abnormal character were developed,
and death was actually produced only by the remote cause of a gan-
grenous  inflammation of the scrotum.
  Second Process.—M. Belmas, carrying out his first idea, considers
that he has at last arrived at a process which will be completely suc-
cessful.   His new method  consists in depositing in the sac, as near
to the ring as possible, small strips of gelatine or goldbeater's skin.
For this  purpose he perforates the whole thickness of the scrotum
with  a  kind of needle canula.   When  the dilated portion of this
instrument  appears to have arrived into the hernial cavity, it is un-
screwed in  order to separate its two halves  in the sac, into which
latter the canula then enables us to introduce small strips of animal
matter.   Adhesive  inflammation supervenes,  the walls  of the sac
agglutinate, and the obliteration of the pouch must be  the  result.
Though M.  Belmas has informed me  that he has already succeeded
by this process, I am nevertheless disposed  to  believe that in most
cases it  will allow the hernia to be reproduced, and that it possesses
still less certainty than that of M. Gerdy.
  I.  A distinguished surgeon of Lyon,  M. Bonnet, has introduced into
practice  a more simple method, or one at least of more easy applica-
tion.  It consists in perforating near the ring the  whole thickness of
the scrotum, comprising the sac also, with several pins, while taking
care to avoid the testicular cord.   These pins, curved back or short-
ened  at  their free extremity by means  of small pieces of cork, are
intended to bring the walls of the sac in contact and to  effect their
adhesion.  Four patients are stated to  have been already cured in
this manner, and M. Mayor of Lausanne, who makes use of a small
seton in  place of a pin, considers it an invaluable method, and one
that is almost always infallible.  As far as I can judge a  priori, this
process, which is nothing in reality but a modification of the ligature
which was formerly extolled so much, or of the simple incision, will
not continue in practice.   Not because it exposes  to much risk, as
some persons appear to apprehend, of wounding the spermatic cord,
but because it can only effect an imperfect  agglutination of the sac
and leaves  the whole length of the inguinal canal open.
  J. M. Malgaigne, with  a view to avoid the cord  with certainty,
and to produce a more extended  obliteration, recommends that we
should perforate the  track of the canal with several needles, and
proceed  to compression by means of  a suitable bandage  as soon as
the neck of the sac is slightly inflamed.
   K. Method of the Author.—Sensible, like other practitioners, of
the want of a radical cure for inguinal  hernia,  and convinced more-
over  for a long time, as I  have elsewhere said, that we were wrong
in abandoning indiscriminately all the trials which had this object in 
RADICAL CURE  OF HERNIA.
227
view, I also have  endeavored to  arrive at it by a special rhethou.
The process which I have proposed is  the  same  as that which is
employed for the radical cure of hydrocele.   I made up my mind to
it  after having acquired the proof that irritating injections in the tu-
nica vaginalis are infinitely less dangerous  when they reach the
peritoneal  cavity than  is generally  supposed.   The  injections for-
merly made trial of, and still used in our day for the radical cure of
ascites, had  already  emboldened me.   The fact  of wine  having
penetrated into  the  belly through a  congenital hydrocele, without
any serious accident resulting therefrom, had afterwards satisfied me
that the  treatment of hydrocele  in  children  could not be attended
with much greater danger than hydrocele in adults.  Passing from
these premises to actual practice, I did not hesitate to inject irritating
liquids into congenital hydrocele ; and I soon obtained the conviction
that by means of the  precaution  of  compressing the  inguinal canal
during the operation (see Hydrocele) there was no danger in adopt-
ing the process  ; from that point to  the idea  of the radical cure  of
inguinal hernia the distance was very trifling.  I had  also remarked
that a hernia coexisting with  a congenital hydrocele had not been
reproduced after an operation had been performed for the latter.  I
then conceived the idea at the commencement of 1835 of attempting
the radical cure of hernia by this  process, especially after it had been
demonstrated to me by  numerous examples that the tincture of iodine
possessed  a decided  superiority  over wine when the object  was to
bring  about adhesive inflammation of the  serous membranes.   I had
already  waited  several months  for an occasion to put this new
method to the test, when I found  myself in a position in which I
was, so to speak, forced to  make use  of it  in the month of February,
1837.  At that period, in fact, I had  at the same time at the hospital
of La Charite two men  who were seized with an acute hydrocele of
the sac, a few days after returning into  the  belly the intestine con-
tained in an  entero-epiploic hernia.   I punctured the cyst and ex-
tracted eight ounces of  serum in  one case, and six in the other.  I
injected  in their place a solution  of  six gros  of tincture of iodine in
three  ounces of water,  and no accident  supervened ;  the sac was
obliterated and the last  time that  I saw the patients, which was three
months after the operation, no appearance had  yet presented itself
of a return of the disease.  Considering myself justified by these
trials to attempt the direct  cure of reducible inguinal hernia, I sub-
mitted a patient  to the iodine injection in the commencement of July,
1837.  I made an incision  about  an inch long through the tunics of
the scrotum down to the external  surface of the sac.   Having  opened
into this latter with the point of a bistoury,  I introduced  into it the
canula of the trochar,  guided upon a blunt-pointed  probe.   After-
wards securing the opening of the sac upon the canula by means of
forceps, I directed an assistant to inject into it the abovementioned
solution, while another assistant, compressing  the inguinal canal, ren-
dered  it  impossible for  the tincture  of iodine to penetrate into the
peritoneal  cavity.   After having thrown the injection upon all the
points of the sac,  I allowed it to run out through the  canula, after
withdrawing which last also I was enabled to reunite the wound  by
means of three points of twisted suture.   Up to the present time the 
228
NEW ELEMENTS OF OPERATIVE SURGERY
 symptoms of reaction have been precisely the same as in hydrocele.
 Without venturing yet to express a decided opinion upon the value
 of this mode of treatment, I consider myself nevertheless justified in
 saying that, a priori, it presents, to say the least, as  many chances
 of success as any of those which have been extolled up to the present
 moment.   As it is in reality nothing more than an experiment, I shall
 avoid  at the present time entering  into a further discussion concern-
 ing its importance; if I have alluded to it in this article, it has been
 rather with the view of fixing its date than to show precisely what
 is my opinion  regarding  it, or  what are the advantages  that might
 be derived from it.

                      §  V.—Appreciation.

   After having  confided for  a long time  upon the efficacy of the
 thousand  remedies successively enjoying a reputation  for the radical
 cure of hernia, it has been finally concluded that this result is next
 to impossible.  The openings through which the viscera escape being
 surrounded by bones  or fibrous cords, have not it  is asserted any
 natural tendency in themselves to close up, and the judgment cannot
 perceive at first how the operations proposed could effect their oblit-
 eration.  All the world, it is added, acknowledge that the  operation
 for strangulated  hernia does not exempt the patient from the neces-
 sity of wearing a bandage.  It remains to know if under this double
 oint of view, we have not allowed ourselves to be imposed upon
 y certain prejudices.  Though it be true that herniotomy does not
 always secure the  patient from a return of the disease, it cannot be
 denied however that  this sometimes happens and  even  quite fre-
 quently.   I could  furnish  many examples of this fact; one among
 others of a young  student of medicine whom I operated on in 1827;
 a second,  still more remarkable, and which relates to a man about
 thirty years of age afflicted with a congenital hernia, and whom I
 operated upon in 1824, at the Hospital of Perfectionnement;  a third,
 that of an adult who had had  an entero-epiplocele for several  years,
 and whom M. Payen operated upon in my presence about the begin-
ning of the year  1831 ;  finally, four or five  others whom  I  have
 since operated upon.  The operation for  hernia  almost of necessity
 produces a wound which  will suppurate, and  the whole surface  of
which  will become covered  with  cellular  granulations as high  up
 as into the ring.   By this means a new tissue is formed which is the
 base of the cicatrix, and which  by its great elasticity and  the adhe-
 sions it contracts with the  surrounding tissues, is certainly calculated
to close up, by a firm consolidation, the track of the hernia.  To
 comprehend correctly  the character of cicatrices  under these cir-
cumstances, we have only to reflect upon the displacements  caused
by those which are usually produced  by burns  of some depth, small
pox, &c.
   For  this result to be produced, however, it  is necessary that the
wound should  have suppurated, and  that the whole surface of the
sac, and even the interior of its neck, should have had time to become
transformed into cellulo-vascular granulations.  If art therefore pos-
 sesses the  power of effecting  a  radical cure of certain hernias, the 
RADICAL CURE  OF HERNIA.
229
   mode by which we are to accomplish this object is to plug up their
   passage, by causing there the  production  of an inodular cicatrix.
   Cauterization is evidently calculated to procure this result, when, for
   example, it is applied to  the entire  thickness of the  scrotal tunics,
   and is made to reach up as high as the internal surface of the neck
   of the sac.  The indirect or direct ligature  is less certain, because it
   acts  only  from without inwards,  and because under  this mode of
   treatment the interior of the ring may not  take on any morbid pro-
   cess.  The loss of substance produced by excision  is a guarantee of
   success  which cannot lead to an  error.   The simple  incision itself
   would also doubtless frequently succeed, if  we decided upon closing
   the wound only  by second intention.   Scarifications  ought still to
•  have the preference over all these processes;  in the first  place, be-
   cause they do not incur the risk of wounding the spermatic cord, as
   is the case in cauterization, nor the vessels,  as in excision; and sec-
   ondly, because they produce  as their result  a cicatrix much more
   solid  than incision properly so called, and  which  they effect more-
   over  with scarcely any more difficulty or embarrassment.   As to the
   method of M. Jameson, should new facts be obtained in confirmation
   of what its inventor says of it, I  should  deem it preferable to many
   of the others.  The tegumentary plug which is inserted into the ring,
   would replace remarkably well an inodular mass of the firmest con-
   sistence, while allowing at the same time of the immediate reunion of
   the wound.  The process of M. Gerdy, M. Leroy and M. Belmas would
   also probably act in the same manner. After the operation for strangu-
   lated hernia,  the crowding back of the sac,  a plug of the epiploon, or
   scarifications, are in my opinion formally indicated, and would, I am
   certain,  result in obtaining radical cures, if at a later period we com-
   bined with it compression properly applied  upon the whole track of
   the canal or ring.   Except for  strangulation, the processes of MM.
   Gerdy, Bonnet, Mayor, &c, ought on account of their being more
   innocuous, to  be  preferred to  the ancient  methods.   Unfortunately
   they can scarcely be attended with success except in rare instances,
   if they are applied exclusively and simply alone.   With me the ob-
   ject would be to irritate and gently inflame the sac as far up as to
   the iliac fossa, and then to keep its walls in  contact for the space of
   several weeks.  The method I would adopt would be according as
   the circumstances existed, the processes of Belmas, Gerdy, Bonnet,
   Leroy, Malgaigne or my own;  the irritation having been produced
   and the  pain subdued, I would establish  upon the whole track of the
   canal, or upon the hernial openings, a methodical  compression with
   the bandages of M. Fournier.
      This  compression being persevered  in and watched  during the
   space of a month or two, and which would not prevent the patients
   from getting up and attending  to some of  their occupations, would
   succeed in at least eight instances out  of  ten, if  the future  should
   not belie what I have already seen of it.  At the  present time, this
   cure,  as a possible result, cannot as I conceive be hereafter called in
   question.  The question only arises to ascertain at what risk it is to
   be obtained.   In itself the operation is in reality neither difficult nor
   very delicate. The lesion of the  testicle, cord and vessels, and the
   different local accidents which  it  may endanger, are  not  inevitable. 
230           NEW  ELEMENTS OF  OPERATIVE SURGERY.

The general symptoms and the peritonitis which have been caused
by it in more than one instance, constitute therefore its principal dan-
gers ; but the few  facts related  by J.  L. Petit, Richter, Abernethy,
&c, should they be deemed sufficient  to put this question forever at
rest ?   The  removal of a loup, and the operation for congenital hy-
drocele have also caused death; no  one  therefore would conclude
that we ought to proscribe these operations, though they are used in
maladies of a less serious character than hernia.  Upon the suppo-
sition that we decide upon  employing it, we must not however ima-
gine that the radical cure of hernia is  applicable to all cases  indis-
criminately.   It  is at the period of youth that it presents the least
dangers and the most chances of success.  The two extremes  of life
are the least favorable to it, because of the intractableness of children,  •
and the rigidity of the tissues in old  persons.  It should generally be
proscribed in old hernias, and such as are of a large size, irreducible
and complicated with extensive adhesions.   We might nevertheless
have recourse to it  with  advantage, should the  enterocele or epiplo-
cele only be restrained at the bottom  of the sac by a bridle, which
could readily be divided by a cutting instrument.  It is clearly indi-
cated for example, when  in  a congenital hernia certain filamentous
adhesions expose the testicle to painful tractions, and to be drawn
up to the ring whenever the viscera re-enter the belly, or when we
endeavor to reduce them.   The dangers that  Zimmerman encoun-
tered  after  a similar operation, were probably owing to the difficul-
ties experienced  by the  surgeon, much more than to the operation
properly so called, and are no argument against it.  Finally, hernio-
tomy never would succeed better than in adults or young persons, in
whom the enteroceles were devoid of adhesions, and not voluminous,
or of  very ancient date.  As soon as the operation is decided upon,
the patient is to be treated and placed in the same way as for  stran-
gulation, whatever in other respects  may be the  method that we have
adopted.  In conclusion, the radical cure of hernia would be too im-
portant a triumph for surgery, and a resource too deeply interesting
to humanity, to permit that  we should not endeavor to improve  it still
more, and to  modify its processes, and to make renewed efforts for
the purpose of attaining  this result.  For myself, I  cannot cease to
entertain the idea, that in the experimental spirit of our age, we may
succeed in obtaining a remedy of this description which shall be of
real  efficacy.   I  must however add,  that it  would be imprudent to
pronounce judgment at this time, and that we  should suspend a de-
finitive verdict, until new facts shall have decisively established the
relative value of the best methods.

            § IV.—Radical Cure of Inguinal Hernia.

   Besides the preceding methods, which are applicable to this as to
every species of hernia, inguinal hernia has given rise to the sugges-
tion of a number of others, which can only be described  under each
head ; such particularly are castration, the  gilded  point,  (le  point
dare,) and the royal suture.
   A.  Castration.—Some of the advocates of excision and of ligature,
or the crowding up of the sac, finding the dissection of the peritoneal 
RADICAL CURE  OF HERNIA.
231
prolongation too  tedious, endeavored to get over this difficulty by
comprising  the spermatic  cord and  the  sac in the same thread.
From this originated  the idea of castration.  To effect this Paul re-
commends  that we should  make a T incision upon the anterior sur-
face of the scrotum.  The  transverse wound serves for  the location
of the ligature,  and  the other for the extirpation  of the testicle.
There are others  who, after having laid bare the testicle at its lower
portion, dissected the cord  and  the sac from below upwards, placed
a ligature around the  whole near the ring, and then made their exci-
sion below the thread.  In  the last century there were persons who
strangulated separately the cord and the  sac before excising them.
Some went so far as  to comprise the cord, sac, and  scrotum in the
same ligature.  This  operation, which was practised with  a kind of
furor by the ancients, is  at the  present  day  interdicted  by law.
Constantine, in order  to suppress this practice in his  dominions, was
obliged to  decree the punishment  of death against those who dared
to have recourse  to it.  Dionis speaks of a charlatan who fed his dog
upon testicles which  had been taken out in this way.   Housse, in
1710, was sent to the galleys for  the same crime.   Castration was
employed not only to cure but  also to prevent hernia.  Thousands
of children have been mutilated for this purpose.  Even women had
the  temerity to meddle with it.  M. A.  Prosse, in  1735, was  sub-
jected to  the punishment  of flogging  at Rheims for such crimes.
After this epoch there was, in the same diocese, a miserable woman
who boasted of having  operated in this  manner on more  than five
hundred  persons.   Some of  our provinces  have been the scene of
such scandalous practices, only a few years since.  Doubtless it would
be a difficult thing  to explain how it happens that, even in our time,
certain beings exist who can make up their minds to set at defiance
morality and the  laws, by performing this operation.  I  am not  so
certain, however, if the  fault is not as much imputable to surgeons as
to the public itself.  In order to proscribe it, medical men have repre-
sented castration, in such cases, as exceedingly dangerous, and fre-
quently liable to cause death.  According to them, on the other  hand,
it could never effect a radical cure, and must always be useless ; but in
these assertions there  is an  extreme exaggeration which goes beyond
the object intended.  An attentive perusal of the ancients proves that
the vast majority of the patients who underwent castration recovered
perfectly, and that numbers of them have been,  by this means, cured
of their hernia.  It is unnecessary  and barbarous, but it must not be
pronounced without efficacy.  The only cases which admit of its
application  are those of a sarcocele or incurable degenerescence of
the testicle, coincident with a bubonocele.  Whatever  Sharp may
say of it, I  do not consider  that adhesions, whether epiploic or intes-
tinal, can require  it, when in any process of kelotomy whatever, they
are found to oppose the reduction  of the displaced viscera.  At the
moment of terminating the operation for strangulated hernia, it is not
sufficient that the testicle should present a little more or less volume
than usual,  and that it  should appear to be  slightly diseased;  it is
also necessary that  it should  have undergone a profound alteration
before any  surgeon, worthy  of this name, should decide upon  re-
moving it;  and it is with extreme surprise that I have met, in the 
232
NEW ELEMENTS OF OPERATIVE SURGERY.
latest work of one of our distinguished masters, two instances of a
course of conduct entirely the reverse.
   B.  The gilded point.—The gilded point  is a process which goes
back as far as to the time  of Oribases, and  which was invented for
the purpose of avoiding the loss of  the testicle, but of procuring,
however, the  same results as castration.   It  consists- in  passing a
golden wire around the cord and sac, and afterwards in making com-
pression  in such manner that this last  only shall be strangulated, and
finally to reunite the wound without  paying any attention to the pres-
ence of the foreign bodv, which the patient was to wear during the
remainder of his life.  This method, which was used in Denmark  by
Buchwall, and by Berrault in France, was not employed altogether
in the same way by Pare, who recommends a leaden wife in place
of that of gold, and that it should be withdrawn after the expiration
of a certain time.  The absurdity of so ridiculous a practice is suffi-
ciently manifest  in  itself to dispense with the necessity of dwelling
upon it.  Any person can immediately perceive that a  ligature ad-
justed in this"manner cannot avoid  the cord  any more than the sac,
and that it would more frequently  result  in atrophy of the testicle
than in the cure of the bubonocele.
  C. Royal suture.—The suture which was denominated royal, be-
cause, according  to J. Fabricius, its object was to preserve the lives
of valuable subjects for the service  of their  kings, is far from merit-
ing the same reproaches as the point dore.   In order to perform this
process, the ancients first dissected the sac, then isolated it  from the
surrounding tissues, and afterwards  sewed it up in its whole length
without interfering with the cord.   But  Sharp proposed to improve
this method, by suturing at the same time and near the ring, both the
sac and the integuments.  Whether by  one  mode or the other, we
perceive that we are not under  the necessity of sacrificing the tes-
ticle, and that it must  present  a better prospect of success  than
the gilded point.  As it is nothing, however, in fact, but  the suture
applied to scrotal hernia, and that scarifications under such circum-
stances  possess the same  advantage as  in every other region, I  do
not deem it necessary that I should dwell longer on the importance
of the royal suture.   All the new methods which I have spoken  of
above, are evidently preferable, and  as they are applicable especially
to inguinal hernia, it does not seem to  me necessary, to discuss at the
present day, the relative value of castration, the point dore, and the
royal suture.

              Article III.—Strangulated Hernia.

  Hernia is sometimes  complicated with accidents, which make it
one of the most dangerous diseases, and the only cure  for which
lies in surgical resources.   The obstruction and strangulation, which
are the most formidable of these accidents, deserve on that account
therefore all the  attention of the surgeon.

                              § I.
  A hernia is  said  to be obstructed, (engouie,) when  the matters
which should escape by the anus, accumulate and are intercepted in 
STRANGULATED hernia.
233
the noose  of the intestine,  which forms the rupture.   Strangula-
tion, on the  contrary, is produced  by the mechanical constriction
which the surrounding tissues exercise, from without inwards, upon
a portion of the alimentary canal, in such manner as to obliterate to
a greater or less degree its calibre.  It is perceived by this definition
that we may in fact  have an obstruction without strangulation, and
vice versa.   Nevertheless, as obstruction rarely becomes dangerous,
except from the strangulation which soon succeeds to it, I see no in-
convenience in following the course adopted by many  authors, who
consider these two accidents only in the light of cause and effect, or
of one following the other, and confine themselves only to the consid-
eration of strangulation.  Strangulation sometimes comes on slowly,
at other times suddenly, exists to a  greater or less degree, and is or
is not complicated with inflammation, but it is nevertheless always
strangulation.
   The term  of incarceration, which Scarpa employs for those cases
in which  the intestine is only distended  in the hernia, and without
having undergone any serious lesion, does not appear to me to  pos-
sess any advantage.    The words, moreover, are of little importance,
provided  we can convey a correct  idea  of the  thing.  A  fibrous
opening in the walls of the abdomen  may yield and be temporarily
dilated from some effort made, and  allow a portion of the viscera to
escape, and it  may  from  its elasticity  or  muscular  action  then
close up, so as to exert a violent  constriction upon  the organ which
has passed through it.  In such cases we have strangulation by reac-
tion of the hernial passages.  In  other cases the contained parts
swell and become more or less  suddenly distended, and by this pro-
truding movement, soon also produce a strangulation, which under
these circumstances is caused by  reaction of  the incarcerated or-
gans.  The first case generally happening suddenly, and in some in-
stances simultaneously with  the hernia, or from receiving the addition
of another  portion of viscera into  the sac which contains it, and being
rapidly followed by inflammation, has received the name of acute or
inflammatory strangulation.  The  second, developing  itself rarely,
except by degrees, and in hernias which  are not usually reducible,
and giving rise to inflammation only after  the  expiration  of  a con-
siderable lapse of time, is denominated chronic or that by obstruction.
Inasmuch as the  openings by which hernias are protruded  are en-
tirely of a fibrous character, it has been supposed that the spasmodic
strangulation suggested by Richter and some others, was a thing im-
possible.  Fages of Montpellier, who, according  to M. Delmas, still
continued to maintain this opinion, endeavored in order to justify it,
to refer this  alledged spasm to the large muscles of the belly ; but
this view of the subject has  not procured it any more partisans, and
I myself have contested it.  New researches, and more exact  ana-
tomical notions  at  the present day, influence me in adopting other
views.  From the species of button-holes which the hernial openings
in fact  represent, being  both contiguously and remotely continuous
with  the muscular fibres, it results that every kind of muscular con-
traction may augment the strangulation of the parts which have pro-
truded there.  (See on this subject  my Anatomie Chirurgical, 3rd
edit., 1837.)
  vol. in.                      30 
234
NEW ELEMENTS OF OPERATIVE SURGERY.
                 § II.—Seat of the Strangulation.

   Though hernias are usually strangulated  at  their root, this acci-
dent nevertheless is observed also at their body.
   A.  In such  cases, it is caused  either by a laceration of the sac,
which has allowed the organs to protrude into the surrounding tissues,
an imperfect septum, or any retraction whatever, or the orifice of a
lateral cell of  this envelope, or by an  abnormal  arrangement of the
displaced viscera, or by some bridles or morbid  tumors.  The torsion
of the intestinal noose upon itself, for example, may  occasion  it.
The same may occur  from  an epiploic band, which  would pass in
front  of the  intestine,  to divide it as it were into two portions,  be-
fore becoming attached to the bottom of the rupture ; and also from an
opening made  by a laceration in this membrane at the middle of the
sac, and through which a part of the intestine shall have protruded.
The epiploon,  rolled up in the form of a cord, may also  become  at-
tached at first  upon one side, and then upon the  other, in such  man-
ner as to form a sort of bridge, and even to make another bridge by
proceeding to  attach  itself again upon the  first wall of the hernial
cavity.  Two of  its prolongations sometimes may approximate, after
having contracted lateral  adhesions,  and may unite a little lower
down, leaving  between them an opening, which is also liable to cause
a strangulation.  All kinds of bridles may also produce the  same re-
sult as the epiploon.   Hey gives  the figure  of one, which,  attached
at its extremities  to the two sides  of the sac, formed at its middle
portion a complete circle, through which the intestine  had protruded.
In a patient, whose dead body I had an opportunity of examining, an
indurated mass of epiploon of the size of a large pullet's egg was  the
canse of the strangulation ;  the same accident  was  produced in a
patient operated  upon by  Pelletan, by an  enormous tumor of  the
mesentery.  The  appendix of the caecum would lead  to the  same re-
sult, if it should be found in the hernia, and should adhere by its point.
The  same  remark is  applicable to the thousand morbid alterations
which are calculated  to produce pressure upon the noose( of  the
intestine and to interrupt the progress of matters through it.  Even
inflammation  of the sac caused by external violence, may produce
strangulation,  as  is proved  by the  case  of the patient mentioned in
the collection  of the theses  of Strasbourg, (1803,) and  who had re-
ceived a spent ball upon the scrotum.
  B.  At its root the hernia may be strangulated in the same manner,
at first as in  the preceding case, and  afterwards by  the opening
through which it has necessarily protruded.  But this opening,  as
we now know, comprises several organs, the constricted portion of
the peritoneal prolongation, and the circle  or fibrous  canal which
contains it.
  I. At first sight it would  appear  difficult that the neck of the  sac
itself  could produce strangulation ; there is no point, however, better
established.  In ancient hernias the  agglutination of  its folds  has
already caused a great increase in  its thickness.  Cellular lamellae,
moreover, are successively accumulated  upon  the external surface
of this neck.  The plastic lymph which is deposited there at  the
same  time  unites the  whole together, and  gradually gives to thia 
STRANGULATED HERNIA.                  235
part a very great degree of density, a thickness in fact which may
become extreme, since Arnaud mentions that it was more than a half
an inch through in one of his patients, and that M. Graefe has seen a
similar case.   A lardaceous, and even semi-cartilaginous appearance
has also been seen here in certain cases; so that this thickening,
arrested externally by the resistance of the ring, is effected at the  ex-
pense of its own proper calibre by a concentric reaction, the whole
of which is exerted upon the intestine.  The  strangulation in such
cases is sometimes so independent of the opening of the  abdominal
walls, that this latter remains wholly free, and so large  as to  enable
the neck  of the sac to move in it with facility; so much  so, that
we might  easily succeed  in returning  the  neck  into  the  belly,
together with the viscera, without in any  respect  diminishing  the
constriction, unless we had  previously divided the latter.   Arnaud,
Le Dran and others were the first to point out this arrangement, which
Riviere, Schenck, Litre and Nuck had only imperfectly  explained,
and the  knowledge  of which  Scarpa, after Pott, Willmer, Hey
and Sandifort succeeded  in diffusing.  In  France  Dupuytren is
among  the number  of those who pointed it  out  in the strongest
manner.  M.  Lawrence,  who at first denied its existence, himself
admits  it in the last editions  of  his work ; while at the present
time this species of strangulation is no longer called in question by
any one.  It presents  even several varieties which are  sufficiently
distinct;  it may be altogether annular, or very circumscribed  foi
example,  and  be  situated  only  at the entrance,  exit,   or  middle
portion of the neck, or it may occupy the whole of this prolongation,
and transform it into a sort of case  or sheath, which  is more or
less contracted.
  II. The aponeurotic opening, which was almost the only  part to
which strangulation was formerly attributed, also produces it in fact,
in a good number of  cases.  But since we have understood  the
difference which exists between the simple ring  and the hernial
canal, a distinction has become indispensable on this subject, in the
same way as for the neck  of the  sac ; that is to  say, that in  the
openings which are  in the form  of a  canal, the  strangulation, far
from existing always at the external  orifice,  as  had been supposed,
may also  be situated  at the  internal  orifice, or' at  an intermediate
point, and sometimes even upon these different parts simultaneously.
  III. Signs of  strangulation.—The most difficult, and at the same
time the most important point to ascertain in  strangulation, is to  dis-
tinguish it  accurately from every  other kind of disease, and not to
confound it with any other lesion.
  A. If the tumor is small, and has not attracted the attention of the
patient, too superficial an examination  might give rise to the belief
that there existed a violent phlegmasia, a volvulus, a poisoning, &c.
These kinds of mistakes are far from being uncommon, even though
the hernia may not be very small.   A surgeon  in  the environs of
Paris was called to a patient, whom he supposed to be laboring under
an attack of gastritis, and whom  he treated  accordingly.  The  ac-
cidents  continued, when a second  surgeon was called in, who  re-
cognized  a strangulated hernia.  A domestic of one  of the public
functionaries died of an  alleged  inflammation of the intestines: it 
236          NEW ELEMENTS OF OPERATIVE  SURGERY.
proved to be a strangulated  hernia, which was not ascertained until
after her death.  A very strong and robust man was seized with vio-
lent colics and convulsive movements.   It was supposed to be a case
of gastritis;  leeches were applied to the epigastrium, and  a  state
of rest recommended  for the' space of three days, when the pa-
tient was brought to La Pitie.  He had a bubonocele, which I was
enabled to reduce immediately.  A little more knowledge and  pre-
caution in such cases would  readily prevent mistakes ; but this is not
always the case, and  the  most  skillful surgeons  sometimes err
on  this point.   In 1817  a woman, who was the  directress of the
nurses of the  Hospital  of Tours,  was  attacked in the night  with
colic,  vomitings, &c. ; I questioned her, and found she had never had
a rupture.  M. Bretonneau examined her  on the following day, and
there  was no trace of rupture found either  at the  abdomen or the
groins.  Nevertheless, the pain increased under  pressure made at
the fold of the thigh,  and  it was from this point that the colics
appeared  to derive their  origin.   A strangulation was suspected;
but what could be done 1  We waited the event, and death occurred
on the following night.   A portion of the intestine of  the size of a
nut, had become strangulated in the  left crural ring, and made no
projection externally.
  B. Peritonitis.—A  number of circumstances  may  lead to the
misapprehension  of a  constriction of  the intestine  in individuals
affected by hernia, as for example, peritonitis when it is  accompanied
with constipation and vomiting.   Pott, upon the recommendation of
two consulting physicians and against his own opinion, decided  upon
operating  on a young man in whom the hernia appeared to be stran-
gulated.   No lesion was found in the tumor ; the patient died, but of
an acute peritonitis.  Pott, called to another  case, was unwilling to
operate.   The death of the patient enabled him to ascertain that the
hernia was not strangulated,  and that the inflammation of the perito-
neum had caused  all the symptoms.  M. Earle, in 1828, was no less
unfortunate.   The operation proved  that  he had been deceived by
an enteritis, and that there was no strangulation.  It is to be observed,
however,  that in these cases   the disease is  usually announced by a
chill of greater or less violence, that the pains are much more acute
in the belly than  in the tumor, that the  vomitings  are glairy and
greenish, and not  stercoraceous, and that the face has a tendency to
become shrivelled and not hippocratic.
  C. An inflamed sac—A no less difficult case is  the following : the
sac of an  irreducible hernia, or the intestine which it encloses, may
become inflamed and give rise to all the symptoms of acute strangu-
lation.  Hernias that are destitute of adhesions are liable to the same
accident.   Sometimes,  however, the ring remains free and makes no
pressure whatever on the organs which  pass through it.   To cause
this inflammation, it is requisite that the pain should have commenced
at the body or base, and not at the root  of the tumor;  that the skin
itself  should have been involved in this inflammation from the be-
ginning, and the laxity of the hernial openings capable of bein°- re-
cognized  by the aid of the  finger.  This result  sometimes actually
takes  place, but when the hernia  has but little volume, how can we
avail ourselves of such circumstances 1  Fortunately in such cases, as 
STRANGULATED HERNIA.
237
in actual strangulation, the operation is  the best remedy to be em-
ployed.   The viscera have been reduced and the tumor reappears.
Symptoms of strangulation supervene ;  the operation is performed,
and the  surgeon finds nothing but a pouch  filled with liquid, either
purulent or flocculated, or serous or sanious.   This  pouch is the in-
flamed  sac, the  inflammation  in  which has closed up the orifice.
Numerous examples  of this kind have been related by Dupuytren and
MM. Duparcque, Sanson and  Janson.   M. Key has  also been de-
ceived in  this manner, and the error could not be dispelled but by the
fact  that it is almost  always practicable  to obtain some evacuations,
and  that the stercoral vomitings do not take place as in true hernia.
  D. Certain hydatoid tumors are to be  ranged in the same class,  as
is proved by  a case published by M. Pigeotte de Troyes, and by
those which have been  mentioned  by Desault, Dupuytren and M.
Roux.  A simple suppurating lymphatic tumor, a cold abscess or one
of an ordinary character, also  come under this description.
  M. Baud in a  case supposed he was operating for  a strangulated
hernia,  but it proved  to be nothing but a lymphatic tumor, upon the
pedicle  of which  he applied  a ligature.  The symptoms became
worse, and the patient died, when it was  ascertained that the thread
applied to the prolongation of the diseased gland, included at the same
time a portion of the intestine.  Purely  fatty tumors expose to the
same mistakes, and have  occasioned them in more than one instance.
Scarpa, under the impression that  the  case was one of strangu-
lation, laid bare  the  supposed  hernia,  and met with nothing but a
pediculated  adipose  mass, which he  excised.  The woman, after
having passed through a number of serious symptoms, ultimately re-
covered.  M. Cruveilhier relates a case in  which the operator, less
fortunate,  lost his patient.  A woman* was seized with colics, vomit-
ings, constipation, &c.  She  had an ancient tumor at the umbilicus.
Being sent for to this  case, I found all the symptoms of a hernial stran-
gulation, threatening  peritonitis.  Before proceeding to the operation,
I deemed  it proper to prescribe a bath,  leeches, cataplasms on the
belly, and enemata of various kinds.  They forgot to send her into
my service from a medical ward, where she was  at La Pitie, and
death took place on the third day.  An acute peritonitis was found,
originating from  an old lesion in the sexual organs, and the supposed
hernia was nothing more  than a pediculated fatty tumor.   A peloton
of epiploon may  be transformed into an hydatid, or into a hard and im-
movable tumor, and may inflame and suppurate, and become a source
of no less  embarrassment, especially if there exists simultaneously a
noose of the intestine in the hernia.  A mower was suddenly attack-
ed with colics and a  desire to vomit, and at the same time noticed
that  a tumor as large as his fist had descended into the scrotum.  He
was  admitted into La Pitie on the seventh day.  The hernia was
composed of two portions ; one above which was soft, and  but slight-
ly sensitive, and  which I succeeded in reducing; the other exceed-
ingly hard, and of larger size, which I found it impossible to return.
The symptoms,  without  being very alarming at first, continued for
the space  of three weeks, and had become  aggravated to  such de-
gree, that the  patient was  at  the point of death, when the suppu-
ration of his tumor put an end to his sufferings, by restoring him  to 
238
NEW ELEMENTS OF OPERATIVE  SURGERY.
 health.  A case nearly  similar is found in the clinique of Pelletan
 The epiploon may mislead also in another manner.  A patient affect
 ed with abdominal hernia, died with symptoms of strangulation. The
 autopsy shewed that the epiploon, which was scarcely affected with
 any disease externallv, was intensely inflamed in the  interior of the
 belly, where it formed a sort of hollow cone, the base of which em-
 braced a perforation of the stomach.

                § IV.—Indications of Strangulation.

   It must have been noticed by what precedes, that strangulated her-
 nia  is a dangerous disease, and  that without  the  succor of art, it
 would be almost constantly fatal.  As  soon as it is  recognized, it is
 important therefore  to put an end to it, and to apply the proper rem-
 edy.   To obtain its  reduction, or to put a termination to the strangu-
 lation, are the objects that are to be had in view.  To  say with Rich-
 ter and Callisen, that we should first subdue the inflammatory tenden-
 cy, pain, &c, in order to diminish the constriction of the parts, would
 be to mistake the effect for the cause, and to attack the consequences
 in place of destroying the principle.   To accomplish this purpose the
 operation is not the only remedy which the surgeon has at his com-
 mand ; this is only his last resource.   Before proceeding to this point,
 the taxis, bleeding, baths, injections, anodynes, and various topical
 applications may and should be made trial of.
   A. Taxis.—The first idea that occurs to us when called to a pa-
 tient with strangulated hernia,  is to endeavor to push it back into the
 abdomen, and this in fact is the  first step that we generally com-
 mence with.
   I. To perform the taxis, the patient  is to be placed in a recumbent
 posture, and in such manner that his muscles may be readily brought
 into a state  of relaxation, commencing as La Sourdiere has  shown,
 with the sterno-mastoid muscles.   The surgeon, placed upon the right,
 embraces the  tumor with one hand,  draws it slightly  towards him,
 as if for the purpose of disengaging it from the  ring, seizes it at its
 neck  with the two or three first fingers of the other hand, then push-
 es it back by small portions at a time, commencing  with those  that
 have  protruded the last, and  causing  them to follow the axis of the
 hernial opening.   In proportion as he returns  one part of it, the fin
 gers of his other hand secure it and prevent it from coming out, while
 the right hand is prepared to push up another part, and  in this way
 in succession, until  there no  longer  remains  any thing more than
 quite  a small mass, which is to  be  pushed up in its totality by means
 of pressure properly applied.  When the reduction is effected  with-
 out difficulty,  this last portion, introduced by the extremities of the
 five fingers of the first hand, passes through the ring without being
 arrested there, accompanied immediately with a characteristic sound
 which is called gurgling, a  bruit which is  caused from the liquids
 which had been before imprisoned in the noose of the displaced intes-
 tine, being now suddenly left to resume their passage alono- the whole
 course of the alimentary canal.
  II.  Epiplocele, which  is moreover distinguished by its irregular
grumulous form, and its soft cakey consistence, does not produce any 
STRANGULATED HERNIA.
239
gurgling sound, nor does it yield with as much facility as enterocele.
The taxis, however,  should be  performed after the same rules in
both cases, except that in the  second the pressure may be carried
much farther without inconvenience than in the first.   When, after
various efforts, a portion of the  hernia is observed to disappear sud-
denly, accompanied with a bruit, while the rest  remains fixed  in the
sac, we may then conclude that  there has been an entero-epiplocele,
and that it is the intestine which has resumed its position.  It  is im-
portant, however, not to forget that an enterocele which has become
strangulated from  obstruction, may readily cause  us to mistake it
for an epiplocele, and that its reduction is not always accompanied
with a gurgling sound.
   III.  If the tumor is small, the  fingers of the left hand are confined
to supporting its contour, while those of the right  hand make pressure
upon it in every direction.   Even  in cases where it has acquired a
certain volume we may still make the attempt to return it bodily, pro-
vided the strangulation has not yet been developed to a great degree,
and that it has been caused by the intestine passing through a simple
ring.  We may  also, when it is very large,  embrace  it with both
hands and compress it over its whole surface at the same time, in the
same way as we would for emptying a bladder filled with liquid.
The gas and semi-fluid matters thus crowded back, sometimes return
into the belly so completely that they put an end  to the strangulation,
or give a remarkable degree of  facility for the subsequent reduction
of the viscera.  This is a process which has succeeded  with me in a
great number of instances.
   IV.  After having in vain made trial of one mode, we must have re-
course to another, and the taxis after all is an operation, the perform-
ance of which  is learned  much better by the practice, anatomical
knowledge, and intellectual resources of each person, than by details
laid down in the best works.  In conclusion, to place the walls of the
belly in a state of relaxation ; to support the neck of the tumor with
one hand, while we push back this last with the other, and in such
way that it may not  fold up on  the borders of  the ring in place of
passing through it; to disengage it a little and to  elongate it, and so to
speak, to knead it, in order to disperse the matters which it contains,
over as great an  extent of surface as  possible ;  to embrace it with
both hands, or only with the ends of the fingers,  according to its vol-
ume ; to cause it to be grasped  even by the hands of  an  assistant,
when it is exceedingly large, while the surgeon supports its root; to
make it pass up in  an inverse direction by the  route which  it has
taken, when it protruded ;  and to suspend our efforts, and to return to
them at a proper time, and to vary their direction and force  without
however going at any time so far as to render them dangerous : such
are the only rules that the operator is under the  necessity of calling
to mind, when  he is about to undertake the taxis.
   V. Prolonged taxis.—I should  add that in large sized hernias,
especially in the epiploic or those that are obstructed, it  is  frequently
advantageous to continue the taxis by means of a methodical com-
pression, until the surgeon resumes  it with his hand, when  he has not
completely succeeded  at first.   It is  this species of prolonged taxis
that M. Amussat and others have extolled in extravagant terms under 
240
NEW ELEMENTS OF OPERATIVE SURGERY.
the title of compulsory taxis, since the period when  I recommended
it in 1832.  In 1825 a man aged forty-seven years, and affected with
an  enormous entero-epiplocele, was admitted into the wards of the
Hospital of Perfectionnement.   Attempts at  reduction, frequently
repeated the evening of his admission and on the following morning,
were attended with no success; but as  there  was  no  evidence  of
inflammation, and that the symptoms developed themselves slowly, it
was considered  safe to delay.   On  the  second day  a trial with the
hand was again resorted to, and the intestine partially returned.  To
prevent its reprotrusion I embraced  the whole of the tumor in a sus-
pensory  padded with compresses.  I  succeeded by this means  in
acting upon it with methodical and sufficiently powerful compression,
which reduced  it to one half during the  night, so that the taxis af-
terwards completed  the work without  difficulty.   The  smoothing
iron, apiece of sheet lead, and a bladder filled with mercury, applied
as weights upon the hernia,  and from  which Wilmer, as well  as
some other English surgeons, state they have derived so much advan-
tage, together with the large cupping glass of M. Koehler are in re-
ality nothing more than compressing  means, for which an appropriate
bandage may be always advantageously substituted.
  VI. Compulsory Taxis.—Though  the taxis may frequently possess
the advantage of rendering a dangerous and painful operation un-
necessary,  it  is  far in  itself from being always devoid of danger.
The viscera, whose  circulation is performed with  difficulty, being
irritated  by the constriction and already  more or less inflamed,  must
necessarily have this  inflammation increased to a still greater  degree
under the influence of such compressions.  Every one knows that if
we did  not proceed with all precaution possible, it would be  very
easy to contuse them, to cause their  mortification or* lacerate them,
and  to expose the patient to the most dangerous consequences.  It
has also  been long remarked that the operation had so much the
fewer chances of success in proportion as the attempts at reduction
had  been  oftener repeated.  There are persons, says  Petit,  who
boast of reducing all descriptions of  hernia ; they compress, destroy
and  inflame the  intestine, and I  have  always had recourse  with
repugnance to the operation in  patients who have been subjected  to
such trials.   Pott recommends that we should not  wait over two
hours, an^  from  the period when he adopted this  prompt course,
almost all his patients were cured.   Before that he lost the half of
them.
  Desault holds  nearly the same language.  Comparative trials had
at the Hotel Dieu, had demonstrated to him, as they  had to Saviard,
(Nouv. Obs. Chir., p. 105,) that the proportion of cures  after  kelo-
tomy was much greater in such persons as were operated upon with-
out having been fatigued by the taxis, than in others.   At the  Hos-
pital of  Orleans, where the operation was performed at the begin-
ning, Le Blanc rarely failed of success, while  at Paris, where it was
not decided upon until at a late period, most of the patients  died.
So that  Richter was  induced to proscribe the taxis.   He avers that
he has rarely seen a hernia that was  really strangulated  reduced by
this  means, and alleges that those  which have yielded to it would
have returned of themselves a few hours later.   These fears, which 
STRANGULATED HERNIA.                  241
are somewhat exaggerated, have no foundation  however, except in
cases of enterocele and  inflammatory strangulation.   In the case
pointed out by Arnaud, the trials must have been very injudiciously
prolonged to have caused the suppuration of the epiploon, or the im-
mediate gangrene of an enterocele strangulated by obstruction, &c.;
but it may be very readily conceived,  that in acute strangulation, the
taxis might, if it had not succeeded, become  dangerous and render the
operation infinitely more formidable  than  if it had been practised
with moderation.  Nevertheless in abandoning  it too soon, we ex-
pose ourselves to the danger of unnecessarily performing a more se-
vere operation.   In many instances, by renewing  it twice, thrice,
four, and even six times, a painful  hernia, which  had  resisted up to
that period, has  been made to return into the belly.   In other cases,
not less numerous trials, though unattended  with success, have not
prevented herniotomy, though performed at the expiration of two or
even three days, from being  followed with  complete success.  Fi-
nally, it has been so frequently noticed that  a strangulated hernia has
been successfully reduced by one surgeon,  after having been in vain
manipulated  by another, that it would  be wrong not to hesitate when
the question  is presented of abandoning the taxis.
   A porter living near me had an ancient hernia, which had become
strangulated the same morning only, in consequence of an effort made
and in spite of his bandage.   Three times  during the course of the
day attempts made to reduce  it had failed.  I saw him in the even-
ing at eight  o'clock, and his suffering and agitation were extreme.
The slightest touch caused him to shriek out.   All the pains came
from the tumor, which could  not endure, it  appeared,  the slightest
degree of pressure.  I nevertheless did not venture to decide upon
the operation until I had performed the taxis again.   I failed in the
first attempt, but a sudden and involuntary  movement of the patient
while I was making a  last trial, finally caused the whole intestine to
return.   The accidents immediately  ceased, and on  the  following
day this man was enabled to resume his customary occupations.
   In the month of March,  1825, M. Demay desired me to see with
him a woman who had been suffering  under a strangulated merocele
for the last 36 hours.   The tumor, which was of the size of a small
egg, was hard and  painful, and evidently  formed by the intestine.
After having submitted  it  to  the taxis, it  appeared to me to have
been slightly diminished,  and I was  unwilling to operate.  I went to
see her on the following  day and attempted the  reduction, but with
no greater success than  on the  evening before.  But as I found it
still further diminished I hesitated, and the operation was again defer-
red a second  time.  At my third visit, 24 hours afterwards, we were
all disposed to wait no longer and to proceed immediately to the re-
moval of the strangulation; but when I had no longer any hope of
success the hernia disappeared under my fingers, and two days after
the patient was in perfect health.
   Although these  facts tend to prove that  in  general we ought not
to follow to the letter the advice  of  Pott or  Richter,  and to lay aside
the taxis after the first trial, I would  not be willing however that
they should give  too much hardihood to young practitioners.  It is
but  too  common  in our day, too, to find what Petit could still ex
   vol. in.                    ^l 
242          NEW ELEMENTS OF OPERATIVE SURGERY.

claim, in his time : " how often  have we  seen patients perish on the
same day even that the reduction has been made !   In some the gut
has been found gangrened, while in others  it had been torn and the
faecal matters dispersed  in the belly."   This  accident happened in
the month of April, 1831, in one of our great hospitals, the very same
day even on which the surgeon had earnestly inveighed against the
danger of a compulsory taxi's.   I am aware of the fact also, that this
accident occurred a short time after in the same establishment.  The
intestine had been lacerated  in both cases, and similar results have
happened in the hospitals of London,  and one especially in the ser-
vice of M. Calloway.   The case mentioned by Lassus is in no way
surprising,  since the young man took the singular idea in his head of
making use of a stick, and to apply one end of it upon the tumor to
make it return while the other was supported against a wall.  Since
that  p'eriod I have collected a greater number of these facts.   The
pernicious  practice having found  new  defenders  in MM.  Herpin
(Journ. Hebdom., 1835, t. III., p. 216) and Diez, and in a surgeon of
Paris, who considered himself the  author of it, and who has had the
boldness to boast of it in a full sitting of the Academy, was speedily
followed by numerous victims.   A person  in the city  was seized
with a  strangulated bubonocele; the surgeon  had recourse  to  the
taxis, and prolonged it to an excessive degree.   The hernia returned
and the patient was supposed to be cured, but  he died on  the next
day  but  one.   The  hernia  from having  been  complete had been
merely  made incomplete, without the strangulation being  removed.
Another  case was  treated in the same manner  during the space of
three days ; he was brought to the hospital, and upon opening the sac
the intestine was found lacerated.   Seven patients who were  admit-
ted to my department in the years 1836,1837 and 1838, were brought
in after 4, 6, 8 and 11 days of similar attempts, and with their intes-
tines gangrened or ruptured.  The idea  of a forced taxis ought so
much the more to be  proscribed, as it is infinitely to the taste of a
great number of practitioners.  Fearful of alarming  the patients, in
proposing a dangerous operation, having  little practice in the opera-
tion  itself,  and justifying themselves  upon  such recommendations,
they make use  of all sorts of manipulations and thus cause acci-
dents which have multiplied in a frightful manner in Paris, since 1834.
In this  question moreover they have set out upon a false principle.
The operation for strangulated hernia is rarely dangerous when it is
well performed, unless there should be already existing a peritonitis
or some dangerous lesions in the displaced organs.  In other respects
it is one  of those operations which succeed the best and  occasion
the fewest  accidents.  It is to be added, that by performing it, there
is a prospect, if we follow the rules which  I have pointed out in speak-
ing of the radical treatment of hernias, that we shall effect a perma-
nent cure for the  patient;  moreover  it is evident  that hernias that
are decidedly strangulated  may be utterly irreducible at the begin-
ning, and that a considerable number of them cannot sustain the taxis
without the greatest danger.  The taxis,  for example, must necessa-
rily be injurious in all cases where the obstacle  to the progress of the
matters is situated in the scrotum, and when the intestine has arrived
to that degree of inflammation that it is upon the point of  becoming 
STRANGULATED HERNIA.
243
perforated or gangrenous.  If the strangulation is at the neck of the
sac or at the posterior ring, or if it is  produced by certain bridles,
the taxis pushes back the tumor between the two rings  and into the
tissues of the parietes of the abdomen  between the peritoneum and
the fascia transversalis; it causes the hernia to disappear externally,
but the strangulation nevertheless continues and  the patients perish
without it being possible to afford them any efficient relief.
   V. Therefore the question is not to reduce the hernia at any sacri
fice, but to know only how to make use of the taxis in a proper man-
ner.   Those hernias that are small, recent and painful, support it with
difficulty, because the opening which has given passage to them is
usually narrow and very much contracted ; and because on the other
hand the intestine thus bridled becomes  inflamed  and altered, or
passes into gangrene with  the greatest rapidity.   The same -remark
nearly applies to hernias which suddenly reappear and become stran-
gulated, after having been for a long time kept  up by a bandage.
The taxis is so much the more dangerous, as the patient is  younger
and more robust and more excitable.
   In chronic strangulatio*n it would be imprudent to operate before
having made repeated trials with the taxis and  even with a certain
degree of force.   Most old hernias come  in this class.   The pres-
ence of a portion of epiploon, of any adipose tissue whatever, or of a
portion of large intestine in the sac, diminishes its dangers, because
these different organs are better enabled to sustain the pressure than
the small intestine. Moreover it is not the time which has elapsed since
the appearance of the first  accidents, which is to be our guide in em-
ploying it, but the condition of the parts.  In some patients the gangrene
or ulceration come on almost as soon as the strangulation.  M. Larrey
says that he has seen this happen at the end of two hours;  Richter
at eight, and M. Lawrence at twelve; while in other cases, which
are apparently similar, and which I  have witnessed, these results had
not yet shown themselves upon the fifth or sixth day.  In 1824 I
operated at the hospital of Perfectionnement upon a woman named
Moliere, who had been laboring under acute strangulation for  the
space of four days.  The intestine though livid was not mortified, and
the cure took place promptly.   Some  months after another woman
was brought into the same establishment to be operated upon for a
similar difficulty.  The  symptoms, which  had only existed twenty-
four hours, exhibited less intensity than in the first case, and  the
hernia was also crural.  Nevertheless the noose of the intestine was
perforated, and notwithstanding it was liberated, death took place in
the course of the night.   Upon opening the  body it was found that
the alimentary matters had passed  into the belly, and that the gan-
grene had invaded a great portion  of the digestive canal.   So long
as the  skin has not yet  become exceedingly sensitive nor positively
inflamed, that pressure upon the tumor does not increase the pain to
too great a degree, and  that there are no evident signs of an actual
peritonitis, there is no reason why we should refrain from the taxis,
unless  it has  already been  put to the test  by experienced persons.
In the contrary case it would be  better  to  renounce it, unless no
attempt has yet been made with it  We have then everything  to
fear even  in supposing that we do succeed, that we  may return into 
244
NEW ELEMENTS OF OPERATIVE SURGERY.
 the  belly  an intestine which  is  half mortified  if  not perforated,
 together with the dark colored putrid and more or less acrid matters
 which usually surround  it in the  sac.   When the hernia, all other
 things being equal, is greatly inflamed, the operation is the most certain
 relief to be proposed for the patient.  Being at this moment scarcely
 more dangerous than the taxis, it has the advantage over it of remov-
 ing the difficulties immediately and of not aggravating the condition of
 the viscera contained in  the  tumor.  At a later period the case will
 no longer  be the same.  The organs  being then contused, greatly
 injured, lacerated and gangrenous, no longer authorize us to form the
 same expectations, and  the  operation  would  only  accelerate  the
 extension of the  disease to the interior,  and the fatal termination.
   VI. Position.—Instead of  placing the patient as above mentioned,
 some surgeons, and Winslow among others,  in the last century were
 in the habit of placing him upon his knees, with the  head low down
 and  supported on his  elbows, during the time while the taxis was
 being performed.   Some credulous or bigoted  persons were in the
 habit of urging the patients, who were thus  prostemated, to occupy
 themselves with fervent prayers,  pretending that if the hernia re-
 turned while they were in this  posture, it would be the interposition
 of Divine Providence that they would have to thank for it.  A much
 more ancient practice, and which  was still used by  Louis, Hey, M.
 Ribes, &c, consisted  in  seizing  the  patient  affected with hernia  in
 such manner as to hang him by his hamstrings upon the shoulders of
 an assistant,  who shook him gently, while  his head and his back
 rested on the bed, or that another person performed the taxis.  It is
 probable that a process of this kind may  not be  of  very great im-
 portance, but it does not appear to  merit the oblivion into which it
 has fallen, nor the ridicule that has  been  cast upon it at the  present
 day.  M. Lawrence is evidently deceived when  he makes  the re-
 mark that the abdominal  viscera are too  exactly supported in every
 portion  of them  for the mere position  of the patient to draw them
 either in one direction  or  another.   We  may be  made at any time
 sensible of the contrary of this, by noticing in ourselves that the in-
 testines  always tend towards the most depending part of the belly,
 as for example, towards  the  hypogastrium in the vertical position,
 and  either to the one  or the other side  according as we are lying
 upon the right or left flank.   I can therefore conceive that by hold-
 ing up a patient  by his hamstrings, there may be  some chance that
 the displaced organs will leave the  hernia to be carried towards the
 diaphragm, which has become in this manner the  lower wall  of the
 abdomen.  There would for the  same reason be danger in doing this
if the intestine or peritoneum  were already  inflamed, or if for  any
 reason   whatever there were grounds  for apprehending danger  in
 any kind of traction made in the direction of the abdomen or hernia.
  Linacier of Chinon, with the view of regularizing this succussion
into a method, and in order to generalize it, contrived in 1819 a kind
of vibratory bed or tumbril, provided with cushions, and upon which
the patient  was adjusted in such manner as to enable us to move him
more or less violently by successively relaxing and elevating the up-
 per part of the apparatus.  This bed, however ingenious it°may ap-
 pear to  be, has not been  and ought  not to be adopted.   In the first 
STRANGULATED HERNIA.
245
place, it has the disadvantage of not always being at command, and
of not being indispensable ; while in the second place, the patients are
stretched out  and extended upon it; whereas in suspending the pa-
tient by his hamstrings, we may keep him flexed and strongly incur- •
vated on  his  anterior surface.   If therefore  we  were  disposed to
make trial of succussion, this last mode of operating ought to be pre-
ferred as more simple and less  dangerous, and as efficacious as any
machines contrived.   There  is  no necessity  of remarking that the
taxis should be renewed with  care, during the time that the assis-
tant or assistants are holding the patient raised up or suspended ;  that
it would be  advantageous also to draw upon the wall of the belly on
the side opposite the hernia;  and that the succussions that are made
upon the  pelvis are not absolutely necessary. M. Kramer, (Klei-
nert's Repert., June, 1835, p. 25,) who makes his patient stand up
and supports his loins with one  hand, wnile with the other he pushes
back  the hernia, would, in my  opinion, very frequently  fail.  As to
gliding in the thumb underneath the  spermatic cord in order to di-
late the ring, as is recommended by Thomson, this cannot be applica-
ble but to inguinal hernias.
   a. Baths.—However little resistance the hernia may make, the
taxis ought not to be employed  alone.   The bath, under such circum-
stances, is an  auxiliary which is scarcely ever omitted.  It calms or
diminishes the pain, spasms, and rigidity of the tissues, the fluxion-
ary movement, and even  the inflammation  itself, if that  should al-
ready exist.   The temperature we give to it is 28  or 30 of Reaumur,
that is, we  make it  somewhat  hot.   The patient is to remain in it
for the space of one or even  two hours.  Desault recommended, that
a sheet stretched at its four  corners, should make in the bathing-tub
a sort of bed upon which the patient might be laid in a gently flexed
position, and subjected to new trials at reduction.   Some practition-
ers return to the taxis one  or several times in the  course of the day,
that is to say, so long as the operation has not been decided upon.
If however  more powerful means have been  already had recourse
to, it would be useless to return  to it, and to waste the  time which is
precious by fruitless essays.   Although the hot bath is  applicable to
almost every description  of strangulation,  it is more especially
adapted to that which is acute, inflammatory, and intestinal, and in
young and robust subjects.   As however, unlike the taxis, it has not
the disadvantage  when it  fails  of augmenting the dangers; and as
in the supposition  even that the  operation should become indispensa-
ble, it cannot but favor the successful issue, I  see no reason for
omitting its employment except  in cases where it is no longer allow-
able to delay.
  b. Bleeding.—The unanimity which prevails among surgeons in
relation  to  the utility of hot  baths in  cases  of strangulated hernia,
does not exist to  so  great a degree upon  the subject of bleeding.
Eulogized beyond measure in such cases by Dionis, by almost all the
Academy of Surgery, by Pott more than  by  any other person, and
recommended by the most distinguished authors of our epoch, it has
nevertheless, so to speak,  been  proscribed by Wilmer, Alanson, and
Sir A. Cooper.  Hey acknowledges also that in most cases it is useless,
and that it is important to  make some restriction  in its  employment. 
246
NEW ELEMENTS OF OPERATIVE SURGERY.
By producing, however, a general  suspension, this* resource is calcu-
lated to facilitate the return  of the displaced organs, to diminish the
resistance of the muscles, the engorgement  of  the tissues, the local
congestion,  and consequently the  volume of the strangulated parts,
and above all the  inflammatory symptoms.   Bleeding pushed as far
as syncope frequently gives such activity to the peristaltic movements
of the  intestines, that  under its influence they will  of. themselves
completely return into  the belly.   It would  also be advisable, when
we wish to  attain this object, to open largely  into the vein, and to
keep the patient in  a  vertical  position while we are bleeding him.
As for the rest, to understand properly the importance of bleeding,
it becomes necessary to specify the cases which  require it.   Obstruc-
tion, epiplocele, and* every  kind of strangulation in old men would
be rather aggravated than relieved by it.  Nor would delicate patients
and ancient hernias always support it without risk, unless it should
have been positively indicated by very decided inflammatory symp-
toms.  In robust and young persons, and in  intestinal, acute, and re-
cent strangulation, it is on the contrary of unquestionable utility, and
should rarely be neglected, were it only for subduing  or moderating
the inflammatory action which has a tendency  to invade the abdo-
men.  We should be wrong, however, to accord to it in any case the
exaggerated importance  which Pott  has  given to  it.  It would be
also unreasonable to count upon  its efficacy after having repeated it
two or three times, even in patients in whom it appears to  be most
indicated.  It is an auxiliary remedy, which like the bath rarely suf-
fices of itself, and is unworthy of so much reliance in fact, except be-
cause it  serves  at the same time  as a precaution against accidents
which might supervene.
  c. Purgatives.—Le Grand, a surgeon of Aries, proposed, in the
last century, the administration of Epsom  salts,  promulgating it as a
kind of panacea for strangulated hernia ; according to him, this sharp
medicine titillates  the  intestine, and frequently induces it to return
into the belly, where it disembarrasses it  of the matters which may
have accumulated in it.  More violent purgatives,  and  emetics to
nauseating doses, as ipecacuanha, for example, have also been recom-
mended.  Richter and Heberden, who made use of these, allege that
they have obtained great advantages from them.  In France these
remedies have never enjoyed much reputation, and the medical opin-
ions which have been current since 1815 have not been calculated to
bring them  into favor  among us, though their irritating action may
be  infinitely less dangerous than  many persons have imagined.  I
would  cheerfully have recourse to them  where there was  only an
epiplocele or adipose hernia, when in  fact the progress of the matters
has not been mechanically interrupted in the alimentary canal, and
even in enterocele which has become strangulated only by obstruc-
tion and does not threaten inflammation.  As  they  encourage the
secretion or exhalation of a greater  quantity of liquids, a more decided
peristaltic movement in all the upper portion of the canal, which may
in  this  manner re-establish the stools or  the softening  of  the ob-
structed matters, we may readily conceive  that under such  circum-
stances  they may have been attended with some success, and that
 here are still at the present day advocates of this practice, as an in- 
STRANGULATED HERNIA.
247
stance of which we may particularize M. Gaussail,  (Journ. Hebd.,
t. IV., p. 93.)   A woman, thirty-two years of age, had reached the
fourth day of a strangulated crural hernia.  Everything had been
made  trial of,  baths,  bleeding,  the taxis, and all kinds of injections.
The belly was  distended and painful, which with the vomitings, con-
stipation, condition of the pulse and aspect of the countenance, left
no  doubt upon the danger of the symptoms that this  woman must
succumb to if the operation was not performed without  delay.  The
patient peremptorily refused to submit to it.   Having nothing farther
to  hope  for, I  granted her anything  she desired.  At her urgent re-
quest, milk and a purgative were administered to her.  She took two
ounces of castor oil in the course of the day.  The  symptoms con-
tinued until five o'clock in the evening, but afterwards became  more
moderate, and at the  time of my  visit on the following  morning, the
pupils who had been watching her were with myself perfectly aston-
ished  to find her out of all danger.   Her restoration was complete.
I have since collected  five similar cases,  and  I consider this remedy
to  be a resource which should be  made trial of more frequently than
it is.  The dose I prefer is composed as follows:  castor oil two
ounces, weak  infusion of mint four ounces, and syrup of lemon one
ounce ; a teaspoonful  every fifteen minutes.
  d. Opiates.—Antispasmodics, opium, and other substances calcu-
lated to modify the system in general, either alone or  associated with
purgatives,  as was the practice of Richter, Heberden. &c, scarcely
deserve  to be brought before the attention of the reader.   The only
advantage that they could promise would  be to calm  momentarily
and to palliate the colics, nausea, severe pains, and some  of the symp-
toms, in  fine, caused  by the strangulation; but to put an end to the
strangulation itself is not their province.   I cannot see how belladona
administered in large  doses,  as js recommended by M. Chevallier,
would act better  than  opium.  "The essence of turpentine, which
MM. Swal and Mac Williams administer to the amount of two ounces
at each dose, and in such manner that the patient may swallow to the
extent of eight ounces in twenty-four hours, will never probably be
made use of in France, and for that reason itself scarcely requires
more than a passing allusion, notwithstanding the successes that are
attributed to it in America.
  e. Enemata.—At the same  time that we are using  either one or
several of the  preceding means, we are in the habit of soliciting a
movement in the large intestine.   The principal object of this being
that of effecting the egress of matters lying below the strangulation,
or at most to produce  an anti-peristaltic motion in the entire alimen-
tary canal, some persons confine themselves to simple lavements, or
laxatives, or ordinary  purgatives.  Riviere,  whose  suggestion has
been  revived by M. Wood,  (Encyclog. des  Sc Med.,  1836, p. 64,)
supposed that by propelling air through the anus by means of a bel-
lows, we should succeed in restoring the displaced  organs into the
abdomen.
•  Hufeland and M. Van Loth, (Gaz. Med., 1830, p. 14,)  professed to
have cured  several patients by injecting in this  manner hyoscyamus
or belladonna, which is also recommended by M. Pauquy.   Lead
water, eulogized in 1835 by M.  Neuner, and which injected to the 
 248          NEW ELEMENTS OF OPERATIVE  SURGERY.

 extent of six ounces, procured three decided successes in the practice
 of M. Rennerth, (Haxthausen, L'Experience, t. I., p. 635,) can yet
 scarcely count in its support anvthing  more than mere assertions.
 But in this point of view, tobacco i"s the substance which has been most
 frequently employed.  It is  administered in the form of tobacco
 smoke, as recommended by Schaeffer, (Acad, de Berlin, t. VII., Ap-
 pend., p. 141,) by means of an apparatus which any person may in-
 vent or construct, or what is  at the same time more  convenient and
 secure, in the form of infusion in the manner of any other glyster.
 In this last case, a gros of tobacco  to a pint of water is the usual
 dose ; one which it would be dangerous to exceed, inasmuch as M.
 A. Cooper has seen it cause a sort of poisoning, which actually took
 place in another case, in which it was administered to the amount of
 two gros, and inasmuch as the same accident has  since happened  in
 the wards of M. Marjolin.  Without agreeing with Heister that it is
 an infallible remedy, or with Pott, that  we have nothing to hope for
 when we have  used this in vain ; and without  according to it  even
 as much confidence as Hey, Lawrence,  Rose, and  most of the Eng-
 lish  surgeons, it  cannot be  denied that  tobacco injections, have,  in
 more than one instance, removed the strangulation and rendered the
 operation unnecessary.  In a case of this kind everything was ready
 for the operation.  Before operating, however, M. Richerand had oc-
 casion to send for something outside of the hospital; during this inter-
 val a tobacco injection  was  administered, and when they  came  to
 look for the hernia, every one perceived to his great surprise,  that it
 had completely returned into the belly.  The symptoms immediately
 ceased, and  the young man left the hospital on the following day, to
 resume his accustomed labors.  It is  true that I afterwards  saw this
 injection used in the same hospital, and that I  myself have since em-
 ployed it in twenty-five cases at  least without any advantage.   The
 oppressio virium, the severe colics, cold sweats, and  tendency  to
 convulsive movements, which it usually  occasions, are evidences of
 the activity of its powers.  As it determines  at the same time vio-
 lent vermicular contractions throughout  the whole  length of the ali-
 mentary canal, nothing can be more easily understood than the effects
 which are attributed to it in strangulated hernia.  For the same rea-
 son  that it is powerful, and  of  unquestionable utility, the tobacco
 may in some cases be attended with danger.  Prudence would for-
 bid its employment where the constriction is very marked, the  her-
 nia recent, purely intestinal, and  complicated with inflammation, or
 the strangulation acute.   On the contrary,  it is  applicable  in all
 kinds of obstruction  or strangulation of the large intestine, or epi-
 ploon, and finally in all cases where the  inflammatory symptoms are
 but  slightly developed,  and  where there is no danger of making
tractions upon the displaced organs with a good deal of force. After
having tried it to the extent of a gros in such circumstances, we may,
and ought in  fact, if  no effect has been produced, recur to it one or
more times, and  increase it then to two gros at least, provided there
be neither narcotism  or other general accidents to be apprehended..
A new method, as it would appear to me, has  been suggested by the
administration of injections  for  the relief of  strangulated  hernia.
M. O'Beirne,  (Dublin Med. and Surg.  Journ., Sept., 1838__Arch. 
STRANGULATED HERNIA.
249
1838, t. III., p. 329,) by introducing a gum-elastic tube into the large
intestine, to the distance of fifteen or twenty inches, for the purpose
of extracting the gases from it, or for pushing up injections, professes
to have succeeded in eleven cases out of sixteen, and M. Grant Wil-
son,  (Gaz.  Med., 1839, p. 106,) has been no less fortunate by inject-
ing in  this  manner a solution of common  table-salt.  I  can  under-
stand,  how in hernias of the large intestine, this description of rem-
edy might possess some utility, but I confess that I cannot comprehend
its efficacy in the others.   I will add that the facts adduced in its fa-
vor have not appeared to me to be conclusive.
   f.  Topical  applications.—Cataplasms,  recommended  and made
use of by a number of practitioners, cannot in reality be serviceable
except in a small number of cases.  If the tumor is neither heated,
nor tense, nor painful, nor actually inflamed, their utility is more than
questionable, unless they should act by their weight; and if the con-
trary state exists, we are not enabled to wait long enough for their
emollient properties to produce any effect; as however, they do not
prevent our having recourse, at the same time, to the bath, bleeding,
and  tjbacco  injections, I see but little inconvenience in applying
them to the hernia in cases of acute strangulation, so long as the ope-
ration is not urgent.
   g. Experience furnishes nothing in favor of leeches, which many
persons apply also upon the tumor or around its circumference, and
which would  be injurious in hernias devoid of inflammation.  In in-
flammatory strangulation itself they could, at  best, act only against
an effect which has occurred, whereas it is the cause which we wish
to destroy.   The ecchymoses,  moreover, which  are produced by
them, have the inconvenience of increasing the thickness of the her-
nial envelopes, of disorganizing them and rendering them more pain-
ful, and thereby rendering  the operation more  difficult.   If they
could ever  be useful they would be, at the farthest, in cases of stran-
gulation, of an inflamed epiplocele, or of some adipose  or other tu-
mor  which was independent of the intestine.
   h. Refrigerants.—Compresses saturated with  cold  water,  iced
water, solution of chloride,  or with  oxycrat;  frictions  with acetic
ether, and  all  those remedies, in fact, which, when applied upon the
tumor, are  calculated to abstract a  large  quantity of caloric, may
favor the reduction of hernia: 1st, as revulsives, by diminishing  the
afflux  of the fluids;  2nd, by reducing  the  quantity of gases in  the
noose  of the  strangulated  intestine;  and  3d,  by encouraging  the
peristaltic action of the alimentary tube.  We thus perceive in what
cases they  may be suitable, and in which  we  may reasonably hope
to derive any advantage from them.  A more active manner of em-
ploying them  is the one which is adopted  by certain old women in
the country, and which is related by J.  L.  Petit.  This author being
sent  for to a young  man, and being accompanied by some of his
brother surgeons,  was about to commence with  the herniotomy,
when the grandmother of the patient coming  into  the chamber, re-
quested everybody to retire, saying  that  she  herself was going to
cure the boy immediately.   After having stretched him naked upon
the floor upon a sheet, she ran to the well to draw a bucket of water,
which  she suddenly dashed  upon the hernia.  The result was, says
  vol.  in.                       32 
250
NEW ELEMENTS  OF  OPERATIVE SURGERY.
J. L. Petit, who had requested permission to remain as a witness to
this experiment, that the intestines almost immediately returned into
the belly, and that the young man found himself cured without an
operation.  Any person may understand the action of such remedies.
and which might be had recourse to with a certain degree of confi-
dence, were it not that in cases where they do not succeed they are
calculated to  favor the development of the various kinds of inflamma-
tions which sometimes succeed to herniotomy.  To leave room, how-<
ever, for the gangrene of congelation, as in the case noticed by M. A.
Cooper, to be apprehended, it would have been necessary for the ice,
snow, or any  other  refrigerant, even the most active,  to have been
employed with very little precaution, and I doubt myself if any such
accident is in reality to be apprehended.
  i.  In these  latter times much has been said of the hyoscyamus and
belladonna for the reduction of hernia.   M. Speziani makes of these
substances a pomade, which he spreads  over the tumor; MM. Meale,
Vignes, (These, No. 208, Paris, 1837,) Joffre, Carre,  Morand,  Porta,
(Brit, and For. Rev., No. 3, p. 269,) Sorbet, (Bull, de Therap., t. V.,
p. 96,) Neuber, (Journ. des  Conn., t. II., p. 86,) Chanel, (Journ. des
Conn., t. I., p. 94,) Perone, (Ibid., t. I.,  p. 60.) Koehler, (Gaz.  Med.,
1830, p. 14,)  Fuzet, (Rev.  Med.,  1831, t. IV., p.  211,)  Bouchet,
(Journ. de Med. de  la Loire Infer, &c,  t. IX., p. 61,) Pages, Faye
and Magliari  have succeeded with the same practice; M. St. Amand
has been no less  fortunate  in employing them  as cataplasms; and
M. Riberi spreads them  upon a bougie,  which he introduces into the
urethra,  and  also alleges to  have  thereby  procured successful re-
sults.   Guerin of Bordeaux long since made use of bougies besmeared
with preparations of opium, and introduced into the  urethra, as a
remedy in strangulated hernia.   I would  not venture to say that we
ought  to place much reliance on such  remedies; but as they  are as
easy in their  application as they are devoid of danger, I do not see
why they might not be had recourse to when we are not under the
necessity of immediately resorting to the operation.  I have made
use of them in six instances.   The tumor besmeared morning and
evening  with pomade of belladonna, was afterwards  covered with
simple cataplasms.   In two instances I  introduced into the anus the
same pomade upon a strong  meche, and I  must confess that  it has
appeared to do good in  a number of patients.   In reference to their
mode of action we must wait, I  should think, for a greater number
of facts  to be adduced  in their favor  before we attempt an  expla-
nation.
  j.  Acupuncture.—I shall not treat in  this place of astringent cata-
plasms, grinder's dust, &c, and of wild pomegranates  and decoction
of walnut leaves, which Belloste states he has found so useful, since
they have been for  a long time  universally  proscribed ; but  I must
say a few words of acupuncture and electro-puncture.  As early as
at the time of Pare  they sometimes ventured to perforate  the  hernia
one or more times by means of a long  needle or small trochar, with
a view of giving exit to the gases contained in the strangulated  in-
testine.  Pott avers that a practice like this is absurd and unworthy
of refutation, and most of  the  moderns are of. the same  opinion.
Nevertheless  it has been put in practice in my presence on a patient 
STRANGULATED HERNIA.
251
 whom I operated upon  immediately after.   I allude to a young stu-
 dent of medicine in whom his father had frequently employed it with
 benefit,   In my opinion it ought to be rejected ; it cannot be ration-
 ally employed except in enterocele which has been distended by gas-
 eous fluids, and' then one of two  things must  happen:  either the
 small wound closes up at the same time that the needle is withdrawn,
 and then the effect is the same as if nothing had been done ^ or this
 wound remains open, and in this case it is to be apprehended that
 when the intestine has  returned into the belly it may allow of the
 escape of some portions  of the liquids which it  usually  contains.
 This last accident however could not occur without great difficulty,
 for every traumatic  perforation of the alimentary canal, the diameter
 of which does not exceed one or two lines, hardly ever fails to be-
 come immediately obliterated, either by the approximation of its lips
 or by the engorgement of its mucous membrane.
   k. Electro-puncture, of which  some trials have  been made on
 dogs by M. Leroy, has not yet been as I am aware applied to man.
 It consists in inserting into the tumor the sharpened extremity of the
 wire of an electrical or galvanic circle, while the other extremity of
 the same circle is placed upon the tongue or in the anus, according as
 the hernia should appear to have been formed either  by the small or
 the large intestine.   Theory would lead  to the  inference that the
 currents  or discharge of a pile of some  strength directed  in this
 manner, were calculated to give rise among the displaced viscera to
 such movements or succussions as to effect, in some instances, the re-
 turn of the hernia into the belly.  After all it is a means which may
 easily be  made use of, and so much  the better inasmuch as we might
 confine ourselves in place of the electro-puncture, to the application of"
 a simple electric circle unaccompanied with needles.
  I. Recapitulation.—Let us now place the operator provided with
 these various  means in presence of a  patient affected  with stran-
 gulated hernia.   Is the case one of ancient enterocele, but which has
 become suddenly irreducible?   If trials have already been made, he
 will  before renewing them place the patient in a bath, or even com-
 mence by bleeding him at the "arm  to a great extent if he is robust
 and  symptoms of inflammation are to be apprehended.   If the taxis
 does not then succeed, the large intestine  is then to  be emptied by
 laxative ^injections, or a purgative will be administered.  The process
 of M. O'Beirne will come next; and the infusion of tobacco in its
 turn, two  or three  hours later.  We will return  again to the  bleed-
 ing if the strength permits,  and to the bath and taxis, or even to
 the prolonged taxis, from which M. Nivet, (Gaz. Med., 1838, p. 481,)
 like  myself,  has obtained  very decided advantages in  cases  of ob-
struction ; next will come the cataplasms or frictions  of belladonna,
and the bougies according to the process of M. Riberi or M. Guerin.'
If all this proves insufficient and there is  no haste, we will  have
recourse to embrocations, cold topical applications, compression, and
finally electricity.  In cases of acute strangulation and recent her-
nia, the taxis, bleeding, baths, enemata, and  cold or  narcotic appli-
cations will have to  succeed each  other rapidly.  If there should
already be inflammation in the tumor, the tobacco injections with
the apparatus of M. Vulpes (Apparech. per Introd. Nell' int. Ret il 
252
NEW ELEMENTS OF OPERATIVE SURGERY.
Fumo di Tobacco, etc., Napoli, 1838,) or any other, and electricity and
compression are no longer admissible.   Nor  is the taxis then to be
performed but with the greatest degree of precaution.  If the pain and
other signs  of inflammation no  longer  leave any doubt as  to the
condition of the parts, bleeding and the bath would be no  more in-
dicated except as  preparatives  ;  all topical applications  must  be
banished and we must proceed to the operation as soon as  possible.
Leeches in  great number  and emollient  cataplasms would  not be
applicable unless the symptoms  should appear to depend upon 3ome
tumor disconnected with the intestine.   When the hernia is formed
of a large intestine or the progress of the  symptoms is somewhat
slow, we commence with the taxis or baths and then  have recourse
to tobacco injections,  topical applications  with belladonna or  opium,
and to refrigerants and even  electricity ; but the bleeding  might, or
can at least, in most cases be  omitted.  We should proceed  in the
same manner when the case is  one of  obstruction only, and  it is in
such cases that during the interval  between the trials with  the taxis,
 jompression by means of a suitable bandage may be of some bene-
fit, in the same way as in cases  of epiplocele, which are  unattended
with adhesions and inflammation.   Finally, after having made trial
of everything  and modified  the application according to the  nature
Df the symptoms, we must no longer think of attempting to  reduce
a hernia of  this description, whether it be that it is restricted  by the
adhesions or that the ring opposes to it an unyielding resistance.  If
 here is still time, the kelotomy,  whose chances of success moreover
are so much the greater, and its  dangers so much the less in propor-
tion as the period is earlier at which we have recourse to it, is to be
no longer deferred.  As the  attentions which the patient requires
after the reduction  are at first the same as after the  operation, we
shall not at the present time dwell any longer  upon  them.

Article IV.—Herniotomy or  Kelotomy,  or  the Operation for
                     Strangulated Hernia.

                        §  I.—Enterocele.

   The operation for  strangulated hernia is  only  known since the
time of Rousset.  Maupasius  appears to have  been the first who
demonstrated  its advantages.   Aymar  and Formi (Bonet,  Corps de
Med., t. IV., p.  108, obs. 101 and p. 194) however had  had  recourse
to it with success in the  sixteenth and seventeenth centuries.   Up to
that period kelotomy was not performed except  for the purpose of
effecting a radical cure  of the rupture.  It is composed of several
stages ; incision of the integuments, division of the tissues placed be-
tween the cutaneous envelope and  the  peritoneal layer, opening oi
the sac, and examination and appreciation of the strangulated p'arts,
the destruction of the strangulation and the reduction ofthe displaced
viscera—such are  the various steps the surgeon  proposes to take
after having arranged his instruments  and the patient and  the as-
sistants.
  A. Articles of Dressing.—A perforated linen besmeared with ce-
rate and  sufficiently large, small balls and plumasseaux of lint   adhe- 
herniotomy or kelotomy.
253
rive plasters, long or square compresses, a long band or an appro-
priate bandage, a straight, a convex  bistoury, the concave bistoury
of Pott, or the straight blunt-pointed bistoury, a good pair of dissect-
ing forceps and straight scissors, a canulated  sound without any cul
de sac, and  some  ligatures and  suture needles, constitute, with the
accessories which are required in every great operation, the different
objects  which we may have occasion for, and  which are to. be ar-
ranged  in order upon a large flat board or upon a small table.
   B.  Position of the patient and the assistants.—The table covered
with a mattrass or the bed upon which the patient is to be  operated
upon, requires  no particular  directions, except that  it  is to be fur-
nished in a proper manner with  alezes.   Nobody at the  present day
imitates Louis, or seats himself upon a stool between the legs of the
patient,  who is supported on the edge  of his bed.  The  operator
stands up or places himself upon his knees,  or sits down and to the
right.    The patient being  placed horizontally and nearer to this
side  of the bed  than the other, is to remain here in a state  of
complete relaxation.   An assistant  watches the movements of his
head and arms, another does the same in respect to the lower ex-
tremities ; a third places himself in front of the operator in order to
stretch the  skin,  sponge the wound, &c.; while the fourth is to re-
main free, and attends to handing the instruments.
   C. Incision of the Integuments.—The parts are to have  been pre-
viously shaved, cleansed, and  wiped.  If the skin is tense, thick, and
adherent, the surgeon, armed  with a convex bistoury, divides it in
the same way as for making a simple incision, from without inwards,
taking  care at first not to go very deep.  In the contrary case, he
takes up a fold, one extremity of which he gives to the assistant, and
then immediately divides it either by puncture from within outwards,
or what is better, from its border to its base.   This fold  possesses
the advantage  of exposing  less to the  wounding of the viscera, in
spite of ourselves; but the incision, which is then  less regular, can
never be prolonged to a sufficient extent with one cut, if the hernia
is voluminous; so that all things being  equal, the  simple incision is
generally preferable when we are sure  of our hand.   The wound
should  have the  direction of the greatest diameter, and  an extent
proportioned to the size of the  tumor.   We do not give it the T or
crucial form, except in some particular cases: I prefer the  crescenti-
form (en croissant) incision.   When the wound is at first not suffi-
ciently long, the operator, in place of gliding successively under each
of its angles a grooved sound,  to enlarge it with a cut of the scis-
sors or straight bistoury, pinches up one of its lips, and directs the
assistant to pinch  up  the other,  in such  manner that the  forefinger
rests in the wound and the thumb upon  the  skin for the lower end,
and the thumb in the  wound and the forefinger on the integuments,
on the contrary, for the upper end; slightly separating while revers-
ing them outwards, the lips of the wound thus embraced, he then en-
larges it with a  convex bistoury as much as  he  deems* necessary.
 By  the other  method we  cause much more pain;, the  skin slips
 upon the sound, folds up and does not admit of being incised but with
 difficulty. The vessels which are opened during this first incision, are
 rarely of sufficient size to render it indispensable to apply the liga- 
254
NEW ELEMENTS OF OPERATIVE SURGERY.
ture to them immediately.  It generally suffices to make slight fric-
tion upon them, or to cause the  finger of the assistant to be applied
temporarily over  their orifice, to  prevent their bleeding: their tor-
sion, moreover, is a very simple affair.
  D. Incision of the  intermediate  tissues.—The division ofthe layers
which come next  to the skin, requires the greatest attention, and is
not to be made but with caution.   In fact they are  not sufficiently
distinct from each other, nor always  sufficiently constant in respect
to their relative thickness, to remove  the  apprehension of wounding
parts which it is important to respect, or to enable us to dispense with
proceeding with an  extreme degree  of reserve, even by feeling our
wav until we reach the sac.   The surest mode is to seize them with
the" forceps in proportion as they present themselves  on  some salient
point of the tumor, to raise up a small flap which is to be excised with
a bistoury flatwise, and to repeat  this operation so  long  as the sac is
not yet laid bare.  The sound being then introduced upwards and
downwards, into this kind of opening, and glided as far as the ex-
tremities of the wound, enables us perfectly well to divide these layers
with security by means of the straight bistoury, or  even'the scissors.
Nobody at the present day would  venture to tear them  with the
pointed sound of Le Dran, or  the fleam which some persons made
use of in  the last century.  It is on our approach to the  sac that the
difficulties commence.  In certain  persons or in certain descriptions of
hernia, it is only separated from the skin by an excessively attenuated
lamella; in others it is found at the depth of some lines, and sometimes
even several inches.   To reach it we are sometimes obliged to pass
through various lardaceous layers, lymphatic  ganglions in a state of
suppuration, and circumscribed or diffused purulent collections : final-
ly, it may be immediately surrounded by a more or less considerable
quantity of dark-colored serosity,  as  has been seen in one  instance,
by both M. Travers and M. Richerand, and which is well calcula-
ted to lead to the belief that we have entered into its interior, or il
may be covered by  various kinds of adipose tissues, which  might
readily be mistaken for the epiploon.
  E. Interposed adipose tissues, (Plaques.)—This last anomaly, the
importance of which classic authors  have omitted to point out, must
necessarily occur frequently.  Saviard (Saviard, Nouc. Obs. Chirurg.,
p. 105,) relates one  instance, and  Scarpa (Traiti des Hernies, &c,
p. 68,) another.   It   was also  met with in a patient operated  upon
by M. Lisfranc, (Arch. Gin. de Med., t. XIII., p. 453.)    I possess at
the present time more than fifteen examples, to which might be ad-
ded those of  MM. Heller (Journ. des Conn. Alid., t.  II., p.  346,) and
A. Andral, (These, No. 293, Paris, 1837.)  Though it be true that a
mistake may  in most cases be avoided, it cannot however be  denied
that we must in some instances  pay particular attention to it.  When
the adipose layer envelopes the sac in the manner of a  network, or
that it is itself surrounded with a lubricated membrane, devoid of ad-
hesions, an arrangement like this  must evidently embarrass the most
skilful surgeons.  M. Roux, in my presence, came near making this
mistake at the Hospital of Perfectionnement.  After having divided
the integuments, and several cellulo-adipose  layers,  he  came down
upon a brownish membrane, very distinct from the others, and which 
HERNIOTOMY OR KELOTOMY.
255
he cautiously opened.  Finding it smooth and unctuous in its interior,
he supposed he had arrived into the sac.   Underneath it was found a
yellowish colored, porous, and very pliant  mass,  but  no intestine.
Fearing that this mass might be a noose of the intestine covered by
the epiploon, M. Roux decided upon dividing it layer by layer, as he
had done with the other tissues.  In place of the intestine, it was the
legitimate  sac which soon presented itself; after which the  hernia
presented nothing remarkable ; Boyer himself had been deceived by
it.  The abnormal production does not always surround  the whole
of the sac.
   In  1829, a patient who had  been  inadvertently placed  in the
medical wards of St. Antoine, was  brought  down  on the following
day into my department.  The strangulation had existed for several
days.  The membrane which I took for the sac being laid open, we
saw before us a mass composed of two portions, one globular, black,
smooth, and  of the size of a  small egg, situated  posteriorly and in-
wards ; the other larger, less dark, bosselated, and incasing the anterior
and outer half of the first.  The idea of an  entero-epiplocele imme-
diately occurred to me.  But in attempting to isolate the adipose por-
tion, in order to proceed to the reduction, I perceived that the intestine
was not  laid bare, and that a semi-transparent lamella still separated
it from the other tissues.  It was the real sac, whose neck gave attach-
ment on its outer surface to quite a large  pedicle of a true adipose
hernia, whifch I excised.  A washerwoman to whom I was sent for by
M. Forget, presented an instance of a no less remarkable arrange-
ment.  I had also laid open a membrane, which might have led to the
supposition of its being the sac.  The tumor that  it contained was
trilobated, and its  three lobes, which were of unequal size, were of
a deep brown color. We immediately perceived that there still was
another covering to the viscera, which it became necessary to divide.
The inner prominence only was connected  with the  intestine ; it
had its own sac.   The two  others also  had a distinct envelope;
they were  pediculated, of an adipose character, and attached to the
external  surface of the  hernial peritoneum.   I excised them after
having reduced the intestinal noose, and the patient  was  perfectly re-
established.  I operated at La Pitie  in October, 1831, on an old wo-
man, who presented an arrangement precisely similar to that of the first
case, and have found the  same arrangement since in various forms
at La Charite, both  in men and women.   These adipose vegetations
may also assume a thousand other different varieties.  Tartra came
down upon a hard  elongated tumor which he could not reduce, and
which he took for  degenerated intestine, and excised with the view
of establishing an artificial anus.   The patient died, but the intestine
had not been touched !   There was not  even an enterocele, and the
part that  had been removed proved to be an  adipose hernia.
  F. A cyst which might have been formed from an ancient  hernia
or other sac, empty like that which was found in the patient operated
on at La Pitie by the method of M. Belmas, or filled with liquid, as
many authors have observed it, would lead to mistakes of another
kind? and which may be readily understood ;  mistakes which might
occur so  much the  more easily, inasmuch as the sac itself  may, after
having been inflamed and then transformed into an  abscess, give rise 
256           NEW  ELEMENTS OF  OPERATIVE SURGERY.
to most of the symptoms of strangulation, as has been already said
above.
   G. State of the sac.—The experienced surgeon, however, aware
of the possibility of so  many errors, will in almost every  case  be
enabled to protect himself against them.  The sac  is not opened  so
long  as  there presents a  woolly,  irregular surface,  and  a me-
lange  of  plates  or  peletons of  an adipose, vascular, cellular  or
lamellar character, or so long as  the neck of the tumor is not free,
and does not allow of our passing around the whole  of its periphery,
as high up as into the ring, by means of the  nail or  the extremity  of
a sound.  Cysts, abscesses, &c. will be distinguished by their want
of communication with the abdomen.   The  same remark applies  to
all morbid productions  situated  outside  of  the  peritoneum.   In
supposing, however, that an  adipose layer might be  mistaken for the
epiploon, what danger would there be in dividing it in order to ascer-
tain what  existed beneath it ?  Unless there  were particular difficul-
ties in the way, however, we should restrict ourselves to dividing the
sac in the  direction of the wound  of the integuments.   In endeavor-
ing to separate it from the surrounding tissues, the surgeon protracts
the operation, augments the amount of pain, and renders mortification
of this prolongation of the peritoneum almost unavoidable if he does
not immediately excise it.
  H. In the  most simple hernias the opening of the sac is an easy
operation, and without any danger for one who is possessed of accu-
rate anatomical knowledge and some degree of skill.  The intestine
constantly exhibits a certain inequality,  and is never as uniformly
globular as its peritoneal envelope, which last, moreover, is usually
separated  from it by a  greater or less quantity of serosity  or  liquid
matter.  It would  be in such cases that we might in some  respects,
as Louis has ventured to assert, divide with one incision the skin and
principal layers which separate it from the  sac, and then penetrate
with a second incision into this last envelope without any further ex-
ploration.   In cases somewhat complicated, such a procedure would
approach  to  rashness, and  in  reality deserve the  censure which
has been  bestowed upon it.  When there is only a certain quantity
of liquid  in  the sac, as in the cases to which M. Tessier's  attention
has been  directed,  (Arch. Gen. de Med., 2e  ser., t. IV., p. 497,) this
would not prevent us from recognizing the presence of the intestine
in its interior.  It would  be the absence or excess of fluid in this pouch
which might lead  us into an error.  It is readily perceived how easv
it would be for us, in the first case, to cut down upon the viscera and
divide  them without being conscious that we had  gone beyond the
sac.   It is readily understood that the difficulty would be still greater
if those different parts were found united by adhesions.  In the second
case, the only danger is  in the possibility of  our confounding the sac
with a large portion of intestine distended by gases or any other fluid
matter, supposing  in such cases that we have not yet been enabled
to distinguish the sac.
  I. Hydropsy of the sac—The presence  of a large  quantity  of
liquid in the sac has  been so frequently encountered, that I must ne-
cessarily say a few words on this subject.   Saviard mentions a case
of this kind,  and  Mery noticed one in a woman in  which there was 
HERNIOTOMY OR KELOTOMY.
257
 more than a pint of liquid.  MM. Liegard and Roux have also each
 seen  an instance  of the  same kind.  Schumcker and Siebold state
 that they were upon the  point of being  deceived by it, and of sup-
 posing  that  they had  come down upon a hydrocele.   Monro avers
 that he has found  more than six pounds of liquid, and Scarpa more
 than three in a single sac.  Pott frequently had recourse to puncture
 for a complication  of this  kind,  and M. Lawrence also appears to
 have met with it.   Finally, M. A. E. Marechal has collected numer-
 ous  examples  of this  kind noticed by him at La Charite.  For this
 result to happen, two conditions are required:  1st. The neck of  the
 sac  must have been shut up  by the strangulation,  or by any other
 cause;  2d.  The peritoneal prolongation has become the seat of an
 unnatural exhalation.  The other affections which might possibly, to
 a certain extent, similate it, are hernia of the bladder, or a hydrocele
 which  should  have an ancient closed hernial sac for its seat, as  has
 been noticed by Bertrandi and Pelletan, (Clin.  Chir., t. III., p.  25,
 111,) or large hydatid cysts developed in a strangulated epiploon, as
 mentioned by  Lamorier.  I have myself seen an  extraordinary case.
 Quite a robust old man was brought into my department at St.  An-
 toine in the month of October,  1828, to be treated for an enormous
 hernia which had been accompanied during the preceding five days
 with  constipation,  vomiting  and  other symptoms of strangulation.
 This  hernia, which occupied the scrotum,  was double the size of an
 adult head, heavy, distended, of a brownish color,  slightly painful, and
 covered with veins greatly injected with blood, and without any pro-
 jection  on  its  surface.  Its walls were  so  thick that the fluctuation
 was obscure, and the light of a candle furnished but little information
 as to its nature.  The patient informed us that he had had this hernia
 for fifteen  years,  during  which  it had not exceeded the size of the
 fist,  and that he had  frequently succeeded in returning it into  the
 belly.   I did not hesitate  to open into it, adopting the same precau-
 tions  as for  an ordinary  hernia, that is to say,  by dividing its  en-
 velopes layer by layer, and on  one point  only.   As  soon as it was
 perforated a clear liquid like urine escaped from it in a jet and with
 considerable force.  I immediately enlarged  the opening and drew
 from it  more than three litres of serosity, which was slightly turbid.
 Its upper part,  moreover, contained an entero-epiplocele which was
 as large as the  fist, strangulated and presenting  several gangrenous
 patches upon it.  Several analogous  cases have since  occurred at
 La Charite.   M. MTlwain, (Encyclog. des Sc. Med., 1838,  p. 94.—
 The  Lancet, 21st July, 1838,) in operating upon a woman for crural
hernia,  found a large cyst filled with serum ; through a neck he was
enabled to reach  a projection  of the intestine, which was liberated,
and the patient recovered.  Was this anything else than a hydrocele
of the sac ?  (See article on Hydrocele.)  By calling to mind the natu-
ral characters of simple hydrocele and cystocele in such cases,  we
shall experience no difficulties.   The mistake, moreover, would not
 be very serious.   Only it is  necessary to recollect that a complica-
tion of this kind renders the efforts for the taxis nearly useless, seeing
that  they are expended upon the liquid before  reaching the intes-
tine, and that, on the other hand, this liquid  must favor the strangula-
tion by  its reaction on the viscera.  The  important point therefore is
  vol. m.                      33 
258
NEW ELEMENTS OF OPERATIVE SURGERY.
 here, as in every other case, not to confound the sac, which is in this
 manner filled with liquid, with the intestine.  To prevent the possi-
 bility of our succeeding  in this, it would be necessary to suppose an
 intimate adhesion between these two parts, a sort of blending of the
 visceral with the parietal peritoneum of the tumor, which is an ex-
 ceedingly  rare  circumstance except in very ancient or in ca;cal
 hernias.
   J.  To distinguish the Intestine.—Unless there should be no sac,
 or where  even adhesions should  exist, we cannot conceive how it
 would ever be absolutely impossible  to  distinguish the intestine if
 we proceed with proper caution.   The  sac in its natural state is no-
 thing but a simple  lamella, and  cannot be  surrounded except by la-
 mella.  Whatever be  its thickness, and whether that  depends upon
 the cellular tissue  which covers its exterior, or upon accidental lay-
 ers deposited upon  its  internal  surface, it  will always present itself
 under the form of concentric laminae  irregularly superimposed  upon
 each other; while  the existence of a fleshy tunic with a double layer
 of fibres underneath a  completely adherent serous membrane, will
 prevent our mistaking  the  intestine or penetrating  into its  inte-
 rior if we are cautious in avoiding it.   A note  of the translator of
 Scarpa, in  which  it is said that  a surgeon divided  the intestine be-
 cause the  adhesions which  united it to the sac did not allow him to
 distinguish  those two parts; 'also  the accident, which happened in
 1831, in one of the great hospitals of the capital, to the surgeon who
 was at the  head of that institution, and  who also opened into the in-
 testinal canal while operating  for a hernia;  as well as many other
 mistakes of the same kind, appear to militate, it is true, against the
opinion which I have just  expressed; but in examining into these
different cases more closely, without reference to the operators, and
 with a desire to ascertain the exact truth, we shall readily perceive
 that the error was not unavoidable, and  that it would be much more
 proper to impute it to the inattention of the operators than to the na-
 ture of the circumstances.   For example, the practitioner mentioned
 by M. Olivier, states that before reaching the sac he was obliged to
 pass through a cyst filled with brown colored serosity.  Now it ap-
 pears to me evident that this pretended cyst was  the  sac itself, which
 was not suspected.  That being the case, it is very natural that the
 intestine should have been  cut  into under the misapprehension that
 the hernial envelope only was being divided.
  K.  Be the case  as it may, we can proceed in  two different modes
 in order to open the sac  The first, and which is generally followed,
 consists in seizing with a common forceps the point which appears
 to be most free, in order  to  raise  up  fiom it a flap which is  excised
 by directing the  bistoury horizontally underneath the extremity of
 the forceps.  The  liquid, if it  contains  any, immediately runs out
 through this opening ; if not, it is the intestine  which immediately
 protrudes into it,  and which is  distinguished from the  sac by its
 greater suppleness, by its smoother aspect and other natural  charac-
 ters.   A sound inserted into this aperture then enables us to  enlarge
 it as much as we desire, by  protecting the  viscera against the action
 of the probe-pointed bistoury, or blunt-pointed scissors which should
 then be used.  The other method is apparently more dangerous, and 
HERNIOTOMY OR KELOTOMY.
259
on  that account  is generally censured  by authors.  Nevertheless I
nave always found it more simple  than the preceding, and I would
not hesitate to give it the preference if  we could always count with
sufficient  surety  on the  hand  of  those  persons who operate for
strangulated hernias.   While the left hand makes sufficient tension
upon the sac or tumor, the right, with a straight bistoury held like a
pen, directs the point gently, and with small cuts upon the projecting
part, divides them layer by layer, enables us in this manner to distin-
guish all  the lamellae  which present themselves, or to stop when
we wish to do so, and to  penetrate with full as much certainty as
by  the ordinary process.   It is  a rule  to open  the sac down to the
lower part of the tumor, in order that  this part may not serve as a
receptacle for pus or other liquids which might accumulate at the
bottom of the wound.  Many surgeons  advise to do the same for the
upper part;  but others recommend that we should not incise in this
last direction only to  a certain distance from the ring.   It is alleged
that the  patient is thereby less  exposed to peritonitis, and  the sur-
geon less in danger of making a mistake when he divides  the ring;
but it becomes then almost impossible to insert the bistoury between
the neck of the serous tunic and the aponeurotic opening, as it is said
has sometimes happened.  If names like those of J.  L. Petit and  A.
Cooper had not   become its defenders, such minute surgery would
not  have required to be specified.  Is it  in fact possible that they
have seriously discussed  the question of ascertaining whether it was
advisable or not to prolong to the distance of a few lines more or less
the incision of the sac in  one direction or another ?  Those who have
performed the operation  for strangulated hernia, will not be able to
understand how the debridement can be made either more or less easy,
or peritonitis be more or less avoided by  one than by the other of these
modes of procedure.  All that we have to accomplish is to lay bare
completely the root of the parts that are to be reduced.  As to the
rest, it is  a matter of little importance whether the incision of the
peritoneal  prolongation be extended as high up  as into  the ring, or
arrested at some  lines this side of it.
  L. Expansion  and adhesion of  the viscera.—The viscera being
now free from every impediment as soon as  the sac is largely laid
open, frequently  acquire  suddenly  a size  much  more considerable
than would have  been  at first supposed; so much so, as to lead  to
the belief, that an additional quantity of intestine has escaped through
the hernial opening.   When the hernia  is voluminous, the inflamma-
tion is frequently  found  to have glued  the different duplicatures to
each other or to the sac.   In such cases, slight tractions, or the fin-
gers glided  between the  parts, will be found  sufficient to separate
them.  Should ancient adhesions  prevent us  from isolating them
completely, a bistoury or the scissors would soon accomplish the ob
ject.  Those general adhesions  only are to be respected, which are
so intimate, as to  make it  impossible for us any longer to recognize
any line of demarcation  between the  sac and  the  hernia.  In en
deavoring to destroy them, it would be  a difficult matter not to make
some mistakes in  the direction o*f the intestine; or if in order  to ob-
viate this  danger, we  should direct the instrument more to the out-
side, the viscera might be left covered with too  thick a layer of ex- 
260
NEW ELEMENTS OF OPERATIVE SURGLRY.
traneous tissues not to render their reduction dangerous.   Should
they be found to jiave been strangulated by a rent in the sac, or with-
in the sac itself  by a rupture, or a bridle of epiploon, or by an acci-
dental  band, or in any other way, we  must also begin by liberating
them, in order to be enabled to unroll them, and to ascertain  if they
are not the seat of some degenerescence, or ulcerated, or gangre-
nous, in a word, if they are in a perfectly sound condition.
.  M. To draw upon the intestine.—After having  thus unrolled them
and spread them out, we are then to proceed in replacing the intes-
tines into the belly, if the constriction of the ring  presents  no ob-
stacle to this step.   In fact, in  a certain number of cases, the thing
is  practicable ; in the first place, when  the abdominal opening is not
the seat of the strangulation ;  again when the course of the matters
has been interrupted only by too sudden an inflexion  of the  organs
upon the hernial orifice ; and lastly, when the substances accumula-
ted in  the  internal  noose, are sufficiently fluid to enable us,  by ma-
king use of exact pressure upon them, to  cause them to return be
hind the ring.   Before doing this, however, whatever may be the
condition of the parts, it is recommended, even after having destroy-
ed the  strangulation, to draw out  all the portion comprehended in
the aponeurotic track.   Without this precaution, it is said, we should
incur the risk of returning into  the belly  a contracted or ulcerated
portion of the  intestine.  There results from  this, moreover, as is
generally  considered, another  advantage, which is, that the noose
being made longer, the  matters it contains would  be dispersed over
a greater surface, distend  the intestine less, diminish the size of each
of its rings, and in this manner render its reduction  more easy.   At
the present time, I have laid aside this practice.   By following it we
might enlarge a laceration or  ulceration  in the intestine, which lat-
ter, moreover, is by this means rendered more difficult of reduction.
If we omit it, we evidently favor, in place of diminishing the pros-
pect of the cure of lesions which might exist behind the rino-.
   N. The coarctation of the intestine in the ring,  is a result admitted
by all authors, and one which the experience  of Ritch had lon°- since
olaced beyond dispute.  In a patient operated upon by this surgeon
the accidents persisted after the reduction, when  the opening of the
dead body explained them ; the portion of the alimentary canal which
had been strangulated,  was found so much contracted that it was
with difficulty that an ordinary quill could be made to pass through
it.  Other examples of contraction of the intestine remainino- in the
belly, have been related since ; I have myself seen some, but it ap-
pears to me that we are deceived  as  to  their  nature, as thev have
nothing about them which is organic or permanent.   They are im-
mediately removed by means of the fingers, when they present them-
selves to our notice; a  purgative generally removes  them after  the
operation, and it would  be barbarous treatment  to stretch the intes-
tine below, as has  been proposed, in order to  enable us to distend
them from the interior to the exterior before proceeding to reduction
   O. A more frequent lesion, and one which has not been sufficient-
ly noticed, is the ulceration of the intestine upon its external surface
The solution  of continuity in such cases, presents itself under  the
form of a groove, which is from one to two lines broad, situated some- 
HERNIOTOMY OR KELOTOMY.
261
times on one, sometimes  on various points, and at other  times even
upon the whole extent of the circumference of the intestine, while  it
corresponds to the fibrous circle which has produced this disorgani-
zation.   It might be  said to have  the  appearance of having been
caused by a packthread drawn tightly around the intestine ; so long
as the peritoneal coat alone is affected, the muscular tunic not com-
pletely perforated, or that the mucous coat  preserves its integrity,
we may return the whole into the abdomen without danger; but the.
greatest degree of precaution would be necessary under such circum-
stances, for these different tunics being at the same time softened, the
slightest traction upon them would instantly cause their rupture, as
I have seen in a woman  operated upon in  the presence of M. Roux,
and who died on the following day.  M.  Lawrence and M. Roux,
who have more  strongly pointed  this out to  the attention of practi-
tioners than M.  Boyer, might have added that this groove has some-
times resulted in a perforation of the  entire intestinal canal,  and in
the production of a fatal  effusion, the origin of which would be very
erroneously explained by a gangrenous ulceration.  In  1824, a wo-
man 55 years of age was  brought to the Hospital of Perfectionne-
ment.   I operated upon  her immediately  for a strangulated  hernia
which had existed for 40 hours.  After having liberated the intestine,
I reduced it with the exception of its  most projecting portion, which
was in a state of gangrene, and the aperture in which  I  attached to
the ring.   The patient died on the next day but one.   The circum-
ference of the organ, which had  borne  the constriction, exhibited
the ulceration above mentioned, and there existed near its mesenteric
border, a perforation through which the matters had passed into the
peritoneal cavity.
   P.  To remove the  strangulation.—Strangulation at the neck  of
the sac takes place only in ancient hernias, and in those which have
come down and  been reduced a number of times.   In the others, in
fact, it would be difficult to conceive how this ring should have be-
come thickened, contracted, and indurated to such degree as to in-
terrupt the course of the matters in the intestine.  When it exists,
we recognize it by the mobility of the peritoneal prolongation, which
permits itself to be pushed up into the belly, drawing the intestine
with it, also by the freedom of the ring in  spite of the  constriction of
the viscera, and  by the facility with which we can introduce  the fin-
ger either wholly or in part, between  the fibrous circle  and the root
of the sac.   If the strangulation is formed by the external orifice of the
hernial canal, the nail directed upon this point will immediately give
evidence of it.  When, on the contrary, it is more deeply  situated, the
opening in question is neither tense nor completely filled  up.  In this
case we shall know that  it is not the entrance into the serous cavity
which has caused it, but  that of the aponeurotic canal, provided the
incomplete reduction of the intestine is not accompanied  by any slip-
ping of the sac.
   I. Dilatation.—Two  different methods have   been proposed to
remove strangulation, viz., dilatation and incision.  Dilatation, which
had already been eulogized by Thevenin, and afterwards by Arnaud,
has been especially recommended by  Le Blanc. Various  instru-
ments  have been devised for that  purpose.  The double gorgeret, 
262
NEW ELEMENTS OF OPERATIVE  SURGERY.
 the two branches of which open and shut in the manner of a dressing
 forceps, would  certainly fulfil  the  object better than any kind of
 crotchet or dilatator whatever, if the  method  itself was worthy of
 being retained ; but the only advantage it possesses, that of protect-
 ing us from any lesion of the vessels, is of too little value  in compari-
 son with its inconveniences,  to cause it ever to be  adopted in gen-
 eral practice.   The impossibility of applying  it when the strangu-
 lation is very deep, its  insufficiency in the majority of cases, the
 contusion of the viscera which  is generally produced by it, and the
 enlargement instead  of the  ultimate contraction of the  ring,  which
 would almost inevitably  result from it, sufficiently justify, in my
 opinion, the oblivion into which it has fallen, and I doubt  if M.  True-
 stedt, who, intimidated by the  fear of wounding the arteries while
 liberating the stricture, has again  proposed its employment, will find
 many imitators among his cotemporaries.
   II.  Incision, or the debridement, consists in dividing at one or
 several points, the free border of the constricting circle.  This is the
 delicate and dangerous part of the  operation;  it incurs the risk  of
 wounding the organs contained in the ring, and  especially the vessels
 of the contour of the hernia.   A multitude of different processes also
 have been proposed to effect this object.
   a. The scissors, curved on their border, employed formerly, are,
 as they should be, proscribed at the  present day.  The same remark
 applies  to the bistoury of Bienaise, an instrument which  seems to
 have suggested the idea of the  lithotome of F.  Come.  The concave
 bistoury of Pott is the one,  at the present day, which  is substituted
 for all other kinds of hernial bistouries.  M. A. Cooper has modified it
 in such a way that its cutting  edge has no more than an extent of
 six to eight lines, and stops at the  distance of from two  to three lines
 from its button-pointed extremity.   According to M. Tesse  of Douai,
 (communicated by  the author,) the  cutting  edge of M. A.  Cooper's
 instrument would be made  still more commodious  if it were  made
 convex upon a straight bistoury.  Constructed  in this manner it in-
 curs less risk of  wounding the parts which, during the debridement,
 might be interposed in front  of its  heel.   This slight  advantage  ouo-ht
 to be adopted, but we must guard ourselves against exago-eratino°its
 importance.  I would even remark  that  in certain  casest when^the
 abdominal  opening has very thick  borders,  and when  the  saw-like
 movements, or those backwards and forwards become necessary it
 is less commodious  than  the bistoury of Pott  properly so called.
 The oval  plate  which M. Chaumas has attached  upon  its convex
 border in  order  to  protect the intestines, is too troublesome and  of
 loo little utility to be spoken of more in detail.   The  object of Du-
puytren, who has placed the cutting edge  upon its convexity and
 which most of those who have since spoken of it do not appear to
 have precisely understood, was to render the curved bistoury better
 adapted to divide the tissues from before backwards, and  from the
 centre to the circumference of the ring.   From thence it was adapted
 only to certain cases, and we shall  soon  see  that even in the cases
 mentioned, the simple straight or common convex  bistoury may be
 advantageously substituted tor it.  The button-pointed bistoury, shar-
 pened that its edge may represent a file, (aiguise a la lime,) invented 
HERNIOTOMY OR KELOTOMY.
263
by J. L. Petit, and the edge of which, too coarse  to divide the ves-
sels, would be sufficiently sharp to cut through the aponeurotic ring,
is of no value  notwithstanding all  the  eulogies which  have been
bestowed upon it.  As to the  ordinary blunt-pointed bistoury, in
many cases it is often less convenient than the curved bistoury, inas-
much as we are sometimes compelled to  pass through a track more
or less tortuous to reach and destroy the constriction.
   b.  The winged  sound of Mery which was  supplanted by the in-
vention of M. Chaumas, and which was  intended to fulfil the same
indication, is no longer found among the instruments of surgery; so
that  in reality the bistoury of Pott is the only special  instrument
which has been retained for the debridement of strangulated hernias.
When there  are  no vessels that we are in danger of wounding, the
concave or even  the  simple blunt-pointed bistoury, if the debride-
ment is to be made upon a ring and not in  the canal, will  answer
and may be substituted.  The nail of the left forefinger is to be first
introduced between the intestine and the constriction which is to
be divided ; the pulp of the finger will then  serve as a guide to the
instrument, the point of which  is to be made to penetrate  into the
belly before turning its cutting edge upon the resisting border.   An
assistant then  attends to the viscera and separates them from the
point which is to be divided; another assistant proceeds in the same
manner in respect tdthe lips of the wound.  The surgeon combining
the movements of his right hand which  holds the handle  of the  bis-
toury with those of the left forefinger which supports its back, then
presses upon the ring which he cuts with a saw-like movement until
it yields  and  is thoroughly divided;  which is made manifest by a
sound similar to that of breaking a piece of tin or unrolling parch-
ment. However,  as this  bruit is caused  by  the division of fibrous
tissue, it  would  be unnecessary to wait for it when  the debridement
is made only upon the neck of the sac.
  c.  On  the supposition that we  should  use  a director, it would be
only as an auxiliary to  the forefinger; we should glide upon it  the
bistoury  which it is to  support during the debridement.  In such
cases it is well that it should have a cul de sac and be curved in such
manner  that the concavity of its extremity  may  sufficiently well
adapt itself to the  inner  side'of the abdominal wall  to prevent any
portion of the viscera from being interposed in front of it, and there-
by incurring  the risk  of being divided at the same time with  the
hernial opening.  It is in such cases that the grooved spatula of M.
Vidal might  be conveniently substituted for  the ordinary director.
If it wrere absolutely necessary to make use of a straight  bistoury or
one without a blunt point, all these precautions doubtless would be
cf service ;  but of what importance can they be where we use the
bistoury  of Pott or any other  bistoury whatever ?  Are not these
rules  more embarrassing than in reality useful ?
  d. Process of Bell.—A convex bistoury or one with a broad point,
like most of the English bistouries, with its back  supported on  the
pulp of the left finger, was directed by Bell in front of the  ring, which
it divided with small cuts, fibre by fibre, from below upwards or from
the centre  towards the circumference, and from the cutaneous to-
wards the peritoneal  side, always taking care  that the edge of the' 
264
NEW ELEMENTS OF OPERATIVE  SURGERY.
 nail went a little beyond the point of the in^'rument.   By this means
 we remove the strangulation  before arriving  at the fascia propria,
 in which the arterial vessels are situated, while no difficulty exists in
 giving to the incision all the extent which is desirable.   This process,
 the advantages of which I endeavored to demonstrate in 1825, and
 which M. Colson and afterwards M. Dellouey have since reproduced
 as belonging to them, in the first place is applicable only to a stran-
 gulation disconnected with the neck of the sac, and that which would
 be  situated at the anterior orifice of a hernial  canal; in the  next
 place it would  be impossible  or  dangerous to have  recourse  to it,
 when the circle to be divided is deeply situated or imperfectly de-
 fined.   However, if  we were desirous of making use of this process,
 the most simple kind  of bistoury, whether convex or sharp-pointed,
 would answer full as well as the bistoury of Bell.   There is much
 less danger moreover of wounding the vessels than is generally sup-
 posed.  These being enveloped in the cellular layer which lines the
 peritoneum and separates it from the fascia transversalis, are always
 thrown to the distance of at least two  lines to the outside of and upon
 posterior surface of  the ring, and this because the internal opening
 of every hernia flares like a funnel,  and that the viscera themselves,
 by being introduced into  it have separated the  vessels from it to a
 greater or  less extent.  On the other  hand, they are sufficiently pli-
 ant and generally so  movable as  to escape in front of the bistoury
 rather than to run  the risk  of being  divided by  its cutting edge,
 should we happen to come in  contact with them.  When the stran-
 gulation is  situated in a canal, we cannot perceive the necessity of
 making the point of the instrument penetrate into the belly, nor  con-
 sequently   what danger there would be of wounding the  blood-
 vessels.
  e. Repeated  Debridements.—In a  case of necessity, moreover,
 there is a  mode by which  we may escape every inconvenience of
 this  kind,   with  almost  absolute  certainty, in cases  where We  are
 obliged to pass  through the entire track of the hernia.  This mode
 consists in  making on the border which strangulates the viscera  two,
 three, four, five, or even ten incisions instead of one.  In multiplying
 them in this manner, we need not give to any of them  more than  a
 line  or  a line and a half  of depth; the enlargement of the opening
 would nevertheless be considerable, and the vessels in reality will in-
 cur no risk of being wounded.  The first idea of this process, which,
 with M. Vidal, I would call multiplied  debridements, and which is al-
 ready found mentioned in Scarpa, and  even in Junker, has lono- since
 been applied in vaginal uterotomy.  M. Mance, of Lyons, had spoken
 of it in the year 1826, and it would seem that Dupuytren also adopted
 it in some cases. But it is to M. Vidal that we are indebted for havino-
 established it as a  precept  in 1827  and in 1831.   M. Dellouey  ha?
 proposed to associate it with the  method of Bell.   For my own part
 I have frequently made use of it in practice, and have every reason
 to consider it worthy of the serious attention of the  operative sur-
 geon.   M. Belhomme, (Arch. Gin. de Mid., January, 1831, p. 114)
 M. Viguerie, (Vignes, These, No. 208, Paris, 1837,)  and M. Cou-
 dray, (Bull, de Therap., t. XII., p.  161,)  have also  pointed out  its
.advantages. 
HERNIOTOMY OR KELOTOMY.                265
  f. What extent ought to be given to the debridement ?—According
to certain authors, an incision of more  than  two or three lines in
depth, would, by enlarging the ring too much, render the return of
the hernia almost  certain, even  though there should be no risk of
wounding the vessels.  There is no doubt that we should confine
ourselves to a small incision, when the constriction is slight, and that
the reduction does  not require any thing more.   On the  contrary,
however  little we may feel the necessity of making a larger debride-
ment, the practice of Sharp, Hey, and Dupuytren, and the  cases of
M. Sanson, (Journ. Hebd., t.  V., p. 465; t. VI., p. 81,) as well as
those of my own, prove that there is no reason for refraining from it.
The incision of two lines  repeated on many points, or the multiplied
debridements, do not  in  this  respect  leave  any excuse  for those
who might  be deterred by the fear of coming  into the vicinity of
important vessels.  As to the relaxation of the hernial opening, we
cannot conceive that it is  a subject of much apprehension, unless it
be in those cases of long slits which are only rendered  necessary in
certain rare cases of deep-seated strangulation.   Should the wound
suppurate, as it almost always does, the inodular tissue which is formed
in front, or even at  the centre of  the ring, in such manner as to con-
stitute the cicatrix,  frequently presents a  greater degree of resistance
to  the viscera, than the  natural  tissues would  have  done.  Under
this point of view the multiplied debridements, moreover, would  still
deserve the preference, because the more numerous the scarifications
of the ring, the more solid is  the cicatrix that will follow, and the
more are  the chances that will exist for the development of the elas-
tic tissue  in question.
   g.  Without opening the sac.—Some authors  also have  supposed
that it would be advantageous and practicable to divide the stricture-
without opening the sac; that we should in this manner have an
operation attended  with but little danger, inasmuch as  it would not
incur the  risk of peritonitis, so common after the  usual operation ; the
viscera, for  the same reason, would  escape all  danger  of  being
wounded; while the  opening of the sac, which is usually attended
with so much fingering, being dispensed with, the  kelotomy could be
performed with confidence and promptitude, and with but little pain.
In such cases, moreover, the debridement in  itself is attended with
no more difficulty than in  the ordinary process.   The bistoury is in-
serted between the  fibrous ring and the neck of the sac, in place of
passing between the sac and  the  viscera; the root of the  hernia is
isolated with somewhat more  caution, in order to  be  better enabled
to recognize the external  surface of the serous prolongation  at its
egress from the abdominal opening, and this  constitutes the  whole
operation.
  J. L. Petit, who became the advocate of this  process,  to  which
Franco, Rousset, Pare and some others  had  already drawn the
attention  of practitioners,  ascribes to it, as Garengeot  and Ravaton
have  since  done,  so  many advantages, that  we  ought not at the
present day  to follow any other if they had a real  existence, and
were   not destroyed   or  counterbalanced  by  its inconveniences,
which  are still greater.   The radical cure, which it is pretended
may be  obtained  by  this process, is  certainly less  probable than
  vol.  in.                      34 
266
NEW ELEMENTS OF  OPERATIVE SURGERY.
 by opening the sac.  If we reduce the  hernia without diviaing its
 peritoneal envelope, it is to be apprehended that the parts contained
 in the sac may have become the seat of alterations which  it is
 important should not be overlooked.  To what  accidents might we
 not  be exposed if the  intestine were gangrenous, ulcerated, con-
 tracted, rolled upon itself, strangulated  by a  bridle, or lodged in a
 rent  of  the  epiploon,  or  should  many  of  these parts be  found
 glued together among themselves 1   A patient operated upon  under
 such  circumstances, by  M. Cooper,  (Gaz. Med., 1837, p. 50,) sunk
 rapidly.  In cases of adhesion the  reduction would be impossible,
 and  this  description of  debridement would be insufficient in  every
 instance  where the constriction was  produced  by the neck of the
 sac.   Let it be added also, that the serum which might be found in
 the hernia, as has  been  said  above, could not be  returned into the
 belly  without  giving rise  to  some  apprehension.  This  method,
 nevertheless, which in a case of necessity might be employed suc-
 cessfully  in recent  hernias, and such as  were of small size,  does
not deserve  the neglect into which  it  has passed.  Certain  cures
adduced  in its favor by M. Gendron, (Bull, de la Fac  de  Med.,
t. VI., p. 131,) Beauchene, M. Key (Arch. Gen. de Med., 2d ser., t. IV.,  *
p. 497,) and other modern practitioners, who have supposed  them-
selves the authors of it, satisfactorily show that  it might still be applica-
ble.  Having laid bare the  sac and divided the ring, the operation, if
we have  succeeded in returning the hernia, is  evidently reduced to a
species of taxis ; and no  one would venture to maintain  that, all
other things  being equal, the  consequences of the taxis could be as
formidable as those of the ordinary operation for strangulated hernia.
What I have said, therefore, for  and  against  the taxis in general, is
 applicable to the debridement without opening the sac.
  h. Process of Franco.—Another kind  of  debridement, which it
 would appear goes back to the time of Franco, is the one which is
 recommended by Pigray.   It  consists in making an incision into the
 parietes  of the abdomen a little above the  strangulation, in  such
 manner as to be enabled by introducing the  fingers into the wound,
 to draw back the  intestine and  return it into the belly.  Rousset,
 who wrote a little  before  Pigray, says that a process like this  had
 been frequently adopted by Duval and his  son as well as by Maupas.
 Heister, who ascribes it  to Cheselden, was evidently deceived on this
 point.  The attempt of  the English  surgeon  appears to have been
 that only of the usual debridement, except that it was by  a  very
 large incision.   It is sufficient I presume,  to  mention  the  operation
 in question, to demonstrate  its dangers and  absurdity.  If, after
 having incised the  anterior  opening of the hernial canal, the reduc-
 tion should be attended with any difficulty, it would be necessary, by
 means of the  finger, to explore the depth of this passage, and to
 ascertain if there did not exist a second strangulation in the direction
 of the belly.   If in this  case the constriction depended  upon the sac,
 we might by drawing upon it by means of the two lips of its  exter-
 nal division, bring it into the  wound  and  divide it without  danger,
 throughout the whole extent necessary,  by  means  of the  blunt-
 pointed scissors or a bistoury.  When this posterior strangulation, on
 the contrary, is caused by a fibrous circle, the traction made  on the 
HERNIOTOMY OR KELOTOMY.
26*?
neck  of the  sac will not be sufficient;  we must then make use of
the curved bistoury, guided by the finger or the director, and proceed
in the same manner as for an external strangulation.
   III. Reduction.—The obstacle which  existed to the return of the
displaced organs being removed, nothing more  remains to be done
than to  proceed to the reduction, properly so called.
   a. After having dispersed in a uniform manner the matters in the
noose before us, we grasp it near the ring with the thumb and two
first fingers ; the right hand embraces the portion which has  protru-
ded the last, pushes it back by making it pass  between the fingers
of the left hand, which prevent it from coming out again, while an-
other portion of the  intestine is to  be grasped and  reduced in the
same manner, and so on in succession until the whole  shall have re-
turned  into the belly.  The forefinger is then introduced into the
canal, in order to ascertain that  the  intestine has properly resumed
its natural position, that it has not deviated through the tissues of the
abdominal walls, that the sac has not followed it, and that it is actually
free of  any bridle or any adhesion that might be calculated to inter
fere any further with its functions.
   b. When a strangulation remains at the posterior part of the sac,
and that this latter has contracted but feeble adhesions with the parts
which surround it, and if the hernia is not of very large size, it may
return  in  mass, by pushing before  it the circle which strangulated
it.  Le  Dran is one of the  first who pointed out this fact, and which
many surgeons have since mentioned.   Under such circumstances
the intestines slip in between the peritoneum and  the  parietes of
the abdomen, and sometimes remain there and become fixed.  As
the constriction has  not been destroyed,  there ultimately takes place
a  laceration and afterwards an effusion into the abdomen.  Arnault,
De La Faye, Leblanc, Bell, and Sabatier, have noticed cases of this
kind, and Dupuytren also appears to have met with several.  It is not
in all cases, in consequence of the resistance of the sac, that the hernia
returns  in this manner without  ceasing to be strangulated.
   c If  the strangulation is situated  at the internal  opening of the
canal, and  has not been removed, the intestines may also  become
lodged between the fascia transversalis and the muscles, separate those
parts, and remain  there equally as well as between the aponeurosis
and peritoneum.   An adult, twenty-eight years of age, whom I ope-
rated upon for an enterocele in  1823, at the hospital of Perfectionne-
ment, presented an instance of this peculiarity.  After  having di-
vided the external opening  of the canal, I  neglected to explore the
posterior ring, and proceeded to the reduction.  As I heard no  gur-
gling, and as the wall of the belly still projected, I passed my finger
to the interior  of the peritoneal cavity, where I recognized that the
reduction was incomplete.  The intestines were brought to the out-
side, and the  left  forefinger  passed into the bottom of the wound,
soon showed me the existence of a  second strangulation,  and which
was produced by the entrance of the fibrous canal.   I effected the
debridement, after which the reduction no longer presented any diffi-
culty.   We must therefore distinguish the return  of the intestines,
between the peritoneum and  the aponeurosis, from that which takes
place between  the aponeurosis  and the muscles, or between the dif- 
268          NEW ELEMENTS OF OPERATIVE SURGERf.
 ferent muscular layers of the  abdomen, and  not confound the ob-
 struction which is produced by the neck of the  sac, with that which is
 owing to the contraction  of the posterior ring of the hernial canal
 When an accident of this kind  has taken place, the first thing to  be
 done would be to reproduce the hernia.  We effect this, by inducing
 the patient to cough, or to make some exertions, and  even to get up.
 Quite frequently also  the viscera come  out of themselves.  If we
 can  reach them, however, with the  finger, it is a still more certain
 mode to pinch them  up and draw them towards  us, doing this with
 all the necessary precautions.  If the difficulty arises from the neck
 of the sac, tractions  made upon  the portion of this envelope which
 has  remained in the wound, would be frequently an excellent means,
 as Dupuytren moreover has long since shown.  None of these re-
 sources, however, would  be a certain guarantee  of  success.   Cho-
 part, Lobstein,  and  other experienced practitioners  have  seen the
 patient perish, notwithstanding  they had  been enabled, in this man-
 ner,  to reproduce the hernia.
  d.   There is  still another circumstance which sometimes prevents
 the organs from being immediately returned into the belly ; this is the
 existence of an ancient and large sized hernia.
  J.  L. Petit having succeeded in reducing a tumor of this descrip-
 tion,   after  much difficulty and fatigue, perceived that the symptoms
 continued and did not cease until he had allowed the viscera to come
 out again.   He explains the fact by saying that the abdominal cavity
 had  become habituated to the absence of the organs, and so con-
 tracted  as  to be incapable any longer of readmitting them, in such
 manner that they had in fact, he says, forfeited the right of domicile.
 When we reflect upon the distensibility of the walls of the' belly, and
 that  in  the  course of the  same day they will allow the stomach and
 rest  of the  bowels  to  acquire double or treble the dimensions they
had  a moment  before, it is difficult to comprehend how their resist-
 ance alone  should be capable of rendering the reduction of any her-
nia whatever impossible or dangerous.  Is it not more probable that
in the neighborhood of the neck of an ancient and voluminous hernia,
 adhesions  have become established between the organs to such ex-
tent  as to render its return difficult;  or that these viscera, which have
been  protruded for so long a time, give rise  to accidents, because
after the reduction they continue pressed together,  agglomerated and
united in a  mass, and do not uncoil themselves freely behind the rino- ?
 This  reflection, which  occurred to me a long time since, and  which
 Petit  the son (Mem. de VAcad.  de Chir., t. II., p. 70, 1819,) had not
overlooked, deserves, in my opinion, to be taken into account.   This
 however should not lead us positively to  deny the explanation of
 J. L. Petit, which is applicable in reality to young  and vigorous per-
 sons  whose  abdominal  parietes are endowed with  a great degree of
 elasticity and a certain thickness, and to those who possess a great
 embonpoint, and in whom the epiploons are loaded  with fat.  In con-
 clusion, it is better to leave  the  intestines in  the sac, after having
 freely liberated them, than to bruise  and injure  them by persisting  in
 attempts to reduce  them.   Experience has shown that retained  in
 this  manner externally, they ultimately return  into the belly gradu-
 ally,  either  entirely or at  least  a  very large portion of them.   The 
HERNIOTOMY OR KELOTOMY.
269
horizontal  position and debilitating  regimen which  the patient is to
be  submitted to,  gradually produces in the belly a species of void
which favors in a remarkable degree in such cases  the effect which
we are desirous of producing.
  e. There are a number of alterations, moreover, in which the re-
turn into the belly would unquestionably be the best remedy.   Thus
the concentric ulceration should not deter us if it is limited to the outer
coat, or even if it has reached to the muscular membrane, if, in a word,
it has not perforated  the  intestine completely.  Nor  is the coarc-
tation of the displaced organ always a  counterindication.  If when
recent  and not  excessive, it allows the  alimentary canal to retain at
least half  its natural dimensions, there is reason to  hope that it will
ultimately  disappear in the abdomen.   Gangrene  is  the accident
which  is  most seriously obnoxious to every attempt at reduction ;
but  for the same  reason we must not allow ourselves to be imposed
upon by false appearances.  However slightly acute the strangula-
tion may be, or however trifling may have been the inflammation or
the duration of the symptoms, the intestine contained in a hernia will
usually be found to be of a deep red  color.   Frequently it will be
found to be brown, blackish or violet colored.  Its peritoneum may
be  separated by small flaps, and this part may have lost its smooth,
moist  aspect, and will appear  rugous, without however being  gan-
grenous.   The fetid odor of faecal matters, which some persons  have
laid down  as characteristic, might also lead to a mistake.  The same
remark applies  to the slaty, grayish or ashy tint.  If its tunics are
not shrunk and flabby, and as it were folded on themselves, if it re-
sists the tractions made upon it, and continues to be dense and  shin-
ing, if the  thickness  of its walls appears to have augmented in place
of having  diminished,  if it retains some degree of heat, and that this
heat is uniform upon all its points when it has remained some time in
the air, and if no perforation exists, there is no gangrene;  we must,
nevertheless, when intimate adhesions, which it is found impossible to
destroy, are encountered, effect the debridement as in ordinary cases ;
only that it is advisable to liberate largely,  in order that the free por-
tion of  the viscera may afterwards be made to return into the belly.
The rest  of the gut is left in the sac, which is covered with com-
presses saturated with  emollient liquids, as in the case of irreducible
large-sized hernias.  The organs being  relieved of their constriction,
and gradually drawn upon by those of which  they are the continua-
tion, frequently succeed also in gradually  returning of themselves
into  the belly, or  at least no longer form in the ring anything more
than a slight tumor, which may afterwards be kept up  by a concave
pelote.

                        §  II.—Epiplocele.

  Epiplocele existing alone rarely strangulates to such degree as to
require debridement, but it is quite common to meet in the  same sac
a noose of intestine and a more or less considerable portion of epi-
ploon.   In such cases it is advisable  before dividing the stricture, to
ascertain if the opening  has not contracted adhesion with the neck
of the sac or the periphery of the intestine.   It  is also proper  to 
270
NEW ELEMENTS OF  OPERATIVE SURGERY.
 make the debridement upon  a  point where there is no epiploon, in
 order not to incur the risk of wounding any of the vessels, sometimes
 quite large, which  are dispersed over this  membrane.  Though it
 usually presents itself the first  on opening into the sac, we must
 nevertheless commence the reduction with  the intestine as soon as
 the strangulation has been removed.   The reduction of the epiploon
 is always attended with more difficulty.   It has almost always under-
 gone some alteration.   If it is adherent to the sac only by means  )f
 bridles or filaments, nothing  is easier than  their destruction.  But
 whenever the adhesions are close and lamellar, it becomes almost in-
 dispensable to remove the part.  If it has  remained a long time in
 the hernia, it becomes loaded with fat and is transformed into an adi-
 pose mass; or it doubles upon itself and becomes covered with pelo-
 tons, cylinders and hard, shining tumors, which have been compared
 to scirrhi.  We meet with those, moreover, of an infinite variety of
 forms, and it would be as  impracticable as it would  be useless to de-
 scribe them all.   If such masses"were reduced with the viscera, sup-
posing that this could be done,  there are some of them whose reso-
lution we might count upon ;  but this could  happen but rarely, and
should they be ever so slightly voluminous, their presence in the ab-
domen would expose to too many dangers to venture upon their re-
duction.
  I. Their excision is unattended moreover with danger when they
are pediculated, as frequently happens, and  when it is not necessary
to excise them through a sound  portion of the epiploon.  M. Payen
and myself operated for an entero-epiplocele in which many of these
productions were developed.  One which was  four inches long  and
fifteen to eighteen lines in thickness, was adherent to the bottom of
the sac  by means of an epiploic band which was still recognizable,
and  was continuous in the direction of the belly  with the same
membrane by means of a  narrow lamella, which was so slightly vas-
cular that its excision was effected without giving rise to the slightest
discharge of blood.  Another  which was  of less length but far more
dilated in its middle  portion, and which had  also a broader root, was
removed in the same manner and without being attended with  any
more inconvenience.  If  their root  moreover should appear to in-
clude vessels of a certain  calibre, nothing would prevent our stran-
gulating them by means of a double thread  before completing their
excision.  Should the epiploon  have preserved its natural state, it
 ought to be reduced.   For this purpose it is to be pushed back by
 degrees, commencing as in the  case of the  intestine  by the portion
 which had come out last, after  having  thoroughly liberated it  from
 all  its  adhesions and  from  every kind of duplicature.  When it  is
 irreducible  some persons recommend, as M. Vidal (Pres. Med., t. I.,
 p. 216) still prefers, that it should be left in the wound, asserting  that
 it will return by degrees  and  that a concave pelote will afterwards
 keep  up the portion which remains outside.   M. Simonin,  (Decade
 Chir., 1838, p. 45,)  by proceeding in this manner, was enabled to
 cure his patient,  though some accidents had  occurred.   Though ex-
 cision is more expeditious  and satisfactory at first  sight, it has not
 been  adopted but by a small number of practitioners.  There are
 three modes of performing it;  1st, in the event of gangrene, to excise 
HERNIOTOMY OR KELOTOMY.
271
between the dead and living parts; 2d, whether there is a gangrene
or not, to divide through the  living parts, to apply no ligature, and
then to proceed to the  reduction; 3d, to divide  through the living
parts and to ligate separately all  the vessels  as they successively
appear.
   The first method is  bad, because  however small a quantity of
mortified tissues  may  be left, their return into  the abdomen must
necessarily be  dangerous,  while if the  bistoury is  carried  through
parts that are still living, we  should incur the risk of causing a
hemorrhage.
   The second has been advocated  by Caque de Reims, who enume-
rates nine successful cases  in its favor.   Like this author, I am satis-
fied  that the  ligature upon the vessels of the epiploon is not always
indispensable, and that in many cases they would cease to  bleed of
themselves after the expiration of a certain period of time.   Never-
theless I should not venture to sanction  his process as a  rule.  I
adopted  it in one instance in  a patient of M. Florence.  Up to this
point the operation  presented nothing peculiar.   It then became
necessary to remove a portion of the epiploon.   The vessels  scarcely
gave out any blood at  first and I proceeded to the reduction.  In the
evening  the blood issued from the wound to a certain extent, when
syncopes and swoonings supervened, accompanied with cold sweats,
and  though the vomitings had ceased, and the matters had  resumed
their course in  the alimentary canal, the woman died ten hours after
having been operated upon.  This suffices for me not to incur here-
after an exposure to such dangers.
   The third method is  the one adopted by Boyer.  To perform this
the surgeon begins by spreading out and unfolding the  epiploon, in
order that he may have to  divide through one membrane only ; then
excises with the scissors or bistoury the portion he wishes to  remove;
immediately seizes with the forceps each vessel  as soon  as it is
divided and forthwith  applies  the ligature to it.   This being done,
nothing more  remains  than to push back behind  the ring the parts
that  have been preserved, and  to  gather the threads on one of the
sides of the wound.  The inconveniences of this  process are that it
requires time, and a laborious research for the vessels, and that it may
expose us to the risk of overlooking some of them which afterwards
might give rise to unpleasant consequences: it would be advisable
to submit it to an important modification.  The threads in fact would
not allow of our abandoning  the epiploon  behind the  hernial open-
ing, and would  compel  us to arrest  it in the ring.   The torsion of the
arteries,  which might  be readily  performed in  such cases,  would
advantageously replace the ligatures and should  be substituted  for
them.  I have used it in two instances, and  am  of  opinion  that but
for this precaution my operation  would have  been attended with
more difficulty.
  II.  The ligature, which was used a long time since, and which had
already been mentioned by Galen, was in the last century the object
of numerous attacks.  J. L. Petit,  among  others, reproaches it with
frightful  consequences.  A patient in  whom he had used  it was
speedily  attacked with  colics, violent pains in the  abdomen,  and ner-
vous symptoms which no one knew  how to explain.   The surgeon 
272
NEW ELEMENTS OF OPERATIVE  SURGERY.
 took off the dressing to see if the intestine had not come out again.
 Finding nothing of this kind, he removed the ligature, when  all the
 symptoms  disappeared, as if  by magic.  From  this  fact  and some
 others, it has been concluded  that the constriction of the epiploon was
 almost as formidable as that of the intestine.   Theory, which is al-
 ways ready to be brought in  support of opinions which practice has
 suggested,  has appeared to furnish an explanation of the phenomenon,
 by indicating the fact that the great sympathetic nerve distributes  a
 certain number of branches to the whole extent of the epiploic mem-
 brane.  Pipelet confined himself to remarking that the dangers  arise
 from  the constriction having rolled up into a cord  a portion  of  a
 membrane  which requires to be kept spread out, and the opinion
 of J. L. Petit has in this manner become  an axiom.   As the ligature
 however is infinitely more easy of application, and that  it protects
 us from hemorrhage with greater security than all the other methods,
 some  practitioners  have not been disposed to renounce  it entirely.
 Hey and Scarpa, for example, assert that by means of a very simple
 modification we may avoid its  inconveniences  without  interfering
 with any of its advantages; the first applies the ligature in the same
 way that the ancients did, but he recommends that we should tighten
 it only by degrees, and  in  such manner  as not  to bring  about the
 mortification of the organ until after the expiration of several days;
 the second  leaves the epiploic plug in  its  place until  it has become
 covered with cellular granulations, and  then strangulates  it  in the
manner of Hey.
  III. The  Author.—The facts related by these authors in favor of
their practice, leave no ambiguity in respect to its innocuousness, and
there  is  no  doubt that it should be adopted by preference if the  liga-
ture in mass were as much to be dreaded as Petit thinks it is.   For-
tunately this is not the case.   In fifteen cases already, I have had oc-
casion to ligate the epiploon, and most of  the  patients have got  well
 without any accident.  When the tumor to  be removed does not ex-
ceed the size of  the finger, it  would appear to me that it might be
embraced without danger  by means of a strong ligature and effec-
tually strangulated at a short distance from  the ring.   On the contra-
ry, I divide the  root into as many portions as  is desirable when it is
larger, in order to  pass a thread around each of them, and to be ena-
 bled to tie them in this manner  separately.   I found  two  were suffi-
 cient in  a woman I operated on in 1829, at  St. Antoine.  The same
 was  the  case in a man  operated upon  by M.  Payen.  In  a lady
 whom I operated on with  M. Gresely, I  was obliged  to  use  seven.
 We then excise all that portion which is outside of the threads, which
 latter are to be collected on one or several points of the ring, and the
 operation is then terminated.  M. Goyrand, (Press. Med., 1.1., p. 215,)
 who has followed this method, has also had every reason to be satis-
 fied with it.  In conclusion, if the epiploon is gangrenous, and we
 wish to return its sound portion into the belly, the best plan is to di-
 vide it through the living portion, and  then to twist  its vessels. If
 the surgeon, on the contrary,  deems it advisable  not  to push it  back
 beyond the hernial circle,  he may confine himself to detaching those
 portions of it which are completely mortified, and without making use
 either of the ligature or torsion.   When it is simply irreducible, with- 
HERNIOTOMY OR KELOTOMY.
273
out having lost its vitality, and when we are obliged to excise it and
then to leave the remainder  in the ring, a  ligature  which would in-
clude the whole of it, or several threads, each of which  would em-
brace a distinct portion, constitute the process which is at once  the
simplest and the safest to be adopted.
  IV.  Some practitioners have considered that after having return-
ed all the viscera into the belly, the sac which is left in the wound,
should in its turn engage our attention.  Those who, like Garengeot,
recommended that it should be liberated without being opened into,
suggested that it should be completely isolated, and then crowded into
the interior of the ring, where it was to be kept up by means of a pelote
of linen or lint.  There are others who have advised to apply a liga-
ture upon its neck to strangulate it, and then excise it.   In cases even
where it has been deemed proper to divide it throughout its  whole
length, it was suggested also that it might be reduced and made use
of to plug up the hernial passage.  Louis earnestly proscribed all
such attempts, maintaining that the reduction of the  sac is impossible,
and that the adhesions upon its external surface do not admit of the
mobility (glissement) which under such circumstances  would  be re-
quired.  On this point, Louis has certainly been deceived.  It is ex-
ceedingly probable that the  sac, whether opened or not, if it were
pushed back in this manner, would  close  up  the ring to a sufficient
extent in some cases to prevent the  return of the disease,  sits exci-
sion and its ligature would not possess the  same advantages, though
exposed to the same inconveniences.  Should it in fact become neces-
sary, in order to remove it, to have  recourse to the cutting instrument,
there would be evidently danger in certain cases at least, of wound-
ing vessels or other parts which it is important should be respected.
I would therefore recommend the  reduction  of the sac  in all cases
where it is found to be almost entirely free, or where its adhesions at
least are so trifling that they may  be destroyed without the  aid of
the bistoury, or any other cutting instrument.  It has been supposed,,
moreover, that when once laid open, and we should not wish,  or did
not find it practicable  to attempt its reduction, it might be advanta-
geous to exsect its flaps.   I  see no objection to a process of this kind,
except that it  is not applicable to hernias surrounded with large sized
arteries and organs of importance.   Nevertheless,  if the borders of
the sac were sufficiently well isolated to enable us to  excise them effec-
tually without wounding any important pavt, the operation could not
but be attended with advantages.  By this means the wound is more
uniform, the suppuration less abundant, and the subsequent treatment
of the operation necessarily  rendered somewhat more simple.
  Dressing.—The dressing, after the operation for hernia, is reduced
to a trifling affair.  A  perforated linen spread with cerate is placed
over the entire bleeding surface, and over this are immediately ap-
plied the small balls of lint.   Then come the  plumasseaux, and com-
presses, and  finally a bandage, adapted to  the kind of hernia for
which the operation has been performed.  In place of a perforated
linen, some persons employ a simple piece of fine  linen.   By being
made larger than the wound, it serves  in some respects as a sort of
chemise to  the lint, and moreover performs the same  offices  as if  it
was perforated;  but as it offers no egress to the discharges, I see no
   vol. m.                       35 
274
NEW ELEMENTS  OF OPERATIVE SURGERY
 reason for  giving it the preference.  Others  confine themselves tc*
 filling the  whole wound with lint without the interposition of linen,
 and then to covering it with plumasseaux, compresses, and the con-
 taining bandage, as in the preceding case.  The principal objection
 to this  practice is, that at the time of the first dressings it rerders
 more difficult the removal of the deep-seated portions.
   I. Immediate  Reunion.—Franco,  who appears to have been the
 first that endeavored to establish as  a  rule, the necessity of laying
 open the hernia, and liberating it at its strangulated portion, recom-
 mends  that we  should  afterwards approximate  the borders of the
 wound  and make use of the suture to maintain them  in contact.
 Most of the surgeons  of that epoch appear to have acted in confor-
 mity to the advice of Franco.  There were none, not even Rousset,
 Pare, Pigray and Thevenin, who did not adopt it.  It had, however,
 been laid aside until about the middle of the last century,  when Mer-
 trud again endeavored to bring it into repute, by maintaining that the
 wound in an operation of this kind  was placed in the same conditions
 as a simple wound.  In  spite of the argument of  Hoin and Le
 Blanc, who adduced  quite a number of facts in their support, the
 process ultimately fell  into disuse, as it  had done in  the century in
 which it had originated.   Union by the first intention, however, ap-
 pears to have been again  made trial of by some modern practition-
ers.  M. Serre  establishes beyond dispute, that  it is in fact possible
 by means of the suture, to cure in a few da*ys the wound which re-
sults from an operation for strangulated hernia.   M. H. Berard also
 informs me that he has  made trial of it  at the Hospital of St. An-
 toine, and that his patient was restored at the expiration of six days.
 Up to this point, as it appears to me, we are perfectly agreed on this
question.  If the point under consideration is only that of the possi-
 bility of this result, there  is no doubt that the practitioner of Mont-
 pellier is perfectly right;  but the important point to examine is the
 utility of such a  procedure.
  II. Secondary Reunion.—When the  hernia is but of  small size
 and recent, and its envelopes preserve a certain degree of thickness,
 and almost all their natural characters, and that the  sac neither rolls
 nor leaves fringes  or flaps whose  mortification at the bottom of the
 wound  might be apprehended ; union by the first  intention would
 certainly take place in  a large number of cases.  When the tumor
 presents a larger volume, and its  coverings  are  attenuated and the
 seat of  various  alterations, and that  the sac is large and has a ten-
 dency to roll up upon itself after the reduction of the viscera, the
 chances of success are  not as  good.   It is then to be feared that a
 suppuration may take place in the midst of the tissues, and separate
 them by extending itself in various directions, and  thus give rise to
 collections and serious accidents.   This is what I have seen in those
 cases where I had deemed  it  prudent to attempt immediate reunion.
 The hernia nevertheless was not very large.   The lips of the wound
 were brought into  accurate coaptation, and were maintained at their
 root by an exact and methodical compression.  On  the fifth day we
 thought we could count  on agglutination having been accomplished.
 On the following  day, however,  we  were undeceived.   Swelling,
 redness, pain and heat manifested themselves below one of the sides 
HERNIOTOMY OR KELOTOMY
275
of the wound ; the inflammation increased and was accompanied by
fever and general symptoms, which were not subdued until after the
opening of an  abscess of considerable size which had insidiously
formed at the lower angle of  the sac.  This immediate reunion,
moreover, appears to me to act in opposition to one of the intentions
of the surgeon,  which is  to favor  as  much as possible the radical
cure  of the  hernia.  Without the necessity of placing the divided
tissues  into perfect contact, we  may with facility approximate them
to a certain degree, diminish to  a greater or less extent their bleed-
ing surfaces, and thus while favoring  suppuration  obtain  a cure  in
from 20 to 30 days.  Ji. patient treated in this manner had his wound
completely closed on the 24th  day.   A  woman whom I operated
upon with M. Forget, (Lancette  Fran$., t. II., p. 354,) was  perfectly
re-established at the end of a month.   After an operation of this de-
scription, would a more rapid cure be a matter of such great impor-
tance as  some persons appear to have  imagined ?  Finally, there-
fore,  except in  a few cases,  secondary union is  the method which
possesses most advantages, and the one which in this operation de-
serves the preference.
   III. When the patient has been once dressed, he is recommended
to make no effort or movement whatever which can react on the ab-
dominal organs,  or that if he is forced  to  cough or contract his
muscles from any cause whatever, he must apply his hand  upon the
front part of the dressing, in order to support it.  Without  these
precautions the intestine might escape a second time, and reproduce
the accidents.  Lassus  relates the case of a  man who, in this state,
had  the imprudence to  leap  out  of bed  and walk   some steps.
The intestines came out in large quantity, and it was with much diffi-
culty that their reduction could be effected.  We must not, however,
allow ourselves to be  too  much alarmed  by such apprehensions.
When the intestine has been once returned into the belly, it does not
very readily come out again.  A slight attack of coughing, or the
moderate exertions made  by the  patient in  turning himself in  bed,
would not  be sufficient  to reproduce the hernia.   If, in consequence
of the debridement, the orifice of the abdominal wall should be found
to have been somewhat larger than usual, the sensitiveness which
has already been established in these parts, or that which the inflam-
mation soon occasions here, forms a kind of barrier which the viscera
rarely pass.  It would appear that a natural instinct prevents their
passing in this direction, and that the patient, even when he does not
think of it, is, so to speak, compelled, as often as he makes any effort,
to prevent this being extended towards the wound.  These remarks
appear  to me to be useful in this respect, that if prudence  ought  to
recommend repose and  immobility of the patient who has been ope-
rated upon, there would also be an inconvenience in forbidding him
to venture to move himself either in one direction or another, or  in
considering the  slightest  exertion as  dangerous; they  will show,
moreover, that there is no necessity of making the  bandage compress
the front part of the wound, and that a containing dressing methodi-
cally applied, will perfectly fulfil the object in view.
  D.  Subsequent  treatment.—Unless  certain particular accidents
should occur, the wound should  not be dressed before the third or 
276          NEW ELEMENTS OF OPERATIVE  SURGERY.
 fourth day, as it is not until then that the suppuration begins to be
 established.  The dressing  is afterwards renewed every  morning,
 and requires no particular directions.  Should certain portions of the
 sac, epiploon, or any other tissue have mortified, they are to be ex-
 cised immediately.  Emollient or chloride lotions, even the decoction
 of bark when the suppuration becomes fetid or grayish or the tissues
 continue pale, or the employment of nitrate of silver when the cellular
 granulations spring up with too much activity, might become neces-
 sary ; but  these different resources are resorted to, under such cir-
 cumstances, from indications which differ in no respect from those
 which require  them in other  kinds of wouno>.   When everything
 goes on well the symptoms of strangulation cease almost immediately.
 Alvine  evacuations come on abundantly at  the expiration  of a few
 hours, and afford  corresponding relief  to the patient.   The pulse
 resumes a  certain degree of force, and  sometimes acquires even so
 much frequency as to constitute a febrile condition, and  it is  not
 until after the expiration of four or five days that this slight reaction
 ceases.   Frequently the functions are not so speedily and completely
 re-established.  The inflammation of the peritoneum may extend  in
 place of being moderated.   The peristaltic movement having been
 disturbed, sometimes experiences difficulty in resuming  its  ordinary
functions, and the  matters are not then  pushed forward with suffi-
cient force  from above downwards to arrive without difficulty into
the lower extremity of the alimentary canal.  This  inaction  in the
intestines may  arise from a slight  degree of inflammation having
taken place in its several  coats in the vicinity of the  hernia.
  I.  If then the stools do  not take place spontaneously at the expira-
tion of two or three hours, we administer a simple enema.   In case
this is not sufficient, we soon give another, which is  of a somewhat
more irritating character.   If after  twelve hours  the evacuations
have not yet taken place, we should have to have recourse even  to
purgative injections, by means  of decoction of senna.  Many prac-
titioners are in the habit of employing at the same time a slight pur-
gative,  administered  by  the mouth.   Dionis, who strongly recom-
mends the  advantages of such a course, states that it was recom-
mended to  him by Moreau, physician of the  Dauphine.  Some  sur-
 geons, at the  head of whom  are  to  be placed Dupuytren and M.
 Green, nevertheless censure its employment, asserting that it must
necessarily promote or aggravate an inflammation, which is already
 too much to be dreaded in persons affected with strangulated hernia.
 At first  sight this reasoning might deceive us, although in reality it is
 easily refuted.  In fact the matters accumulated in the intestines are
 a powerful source of inflammation.  Now the best  means of sub-
 duing or preventing this inflammation, is to force these  matters to
 escape by the rectum.  In this respect the purgative injections  and
 drinks of the same nature possess an efficacy which no one  can  call
in question.  At the hospital  of Tours, I have seen M. Gouraud ope-
 rate in quite a great number of hernias;  he  administered to all his
patients a purgative  dose almost immediately after, and no where,
as far as I know, was there a Jarge proportion of cures.  Boyer, who
was in  the same practice, was also deemed exceedingly fortunate
in this description of operations.  As to the nature of the purgative, 
HERNIOTOMY OR KELOTOMY.
277
this may be of different kinds.  Some give one  or  two ounces of
castor oil in teaspoonsful at a time, and others employ Epsom salts.
The purgative which I have seen M. Gouraud administer, is com-
posed of an ounce or two of manna dissolved in a glass of infusion of
mint.   There  are those who  prefer dissolving this  last mentioned
substance in four ounces of red wine.   The  common prejudices are
opposed to the use of this vehicle, and I have no personal experience
in its favor.  The purgative I prefer is castor oil in infusion of mint,
with syrup of lemons.   I notice with  pleasure that this  practice, in
favor of which M. Tessier has adduced new facts, counts at the pre-
sent day a number of advocates.  It is  unnecessary to add, more-
over, that in my opinion the administration of a purgative is  not in-
dicated, and is at least  unnecessary when  the stools appear spontane-
ously, and that there is no evidence of any intestinal  disturbance.
  II. When instead of a mere obstruction, there are found to  be
symptoms  of actual inflammation, or manifestations of peritonitis,
notwithstanding the re-establishment of the course of alimentary
matters, we should  unhesitatingly subject  the patient to the most
energetic antiphlogistic treatment.  One  or more bleedings  by the
arm, one or several applications of leeches to the  number of 20, 30,
40, and even 60 if the strength of the patient permits, should  be im-
mediately prescribed if, in the space of twenty-four hours, the inflam-
mation should not be reduced, but, on the contrary, have a disposition
to extend and become general.  Nor can I perceive why the  mercu-
rial treatment and salivation might  not also be advantageous, or
what objection there would be in applying every two or three hours
friction  upon the belly with two  or  three gros of Neapolitan oint-
ment, together with  the  administration internally of two grains  of
calomel every two hours.  The cases of  puerperal, simple and trau-
matic peritonitis, which have evidently yielded to this treatment, are
a sufficient authority for not omitting it  under the present circum-
stances, when the  sanguineous  evacuations no longer afford any
prospect of success.
  III. These unfortunately, however, are not the  only difficulties
after kelotomy, which may present an obstacle to the re-establish-
ment of the functions.   Besides the return in mass of the intestine,
which continues to  be strangulated at the neck of the sac, or which
becomes lodged between the parietes of the abdomen,  we have to
apprehend  moreover  that the noose which was outside, may. in en-
tering have passed above  or  below an  abnormal bridle, which  is
sometimes found in the neighborhood of hernial openings.  It is also
possible that the portion which has been reduced, may form an angle,
and one so acute as not to allow of the passage of the matters, as is
proved by a case of Lassus.   The same difficulty may arise from the
intestine having become twisted upon itself  in such manner as to
close up its passage  completely.  It may  moreover have  slipped
through a tear in the epiploon, or in  some  old false  membranes, or
in the mesentery.
   Finally if, after the  reduction of the viscera, the  vomitings, pain
and distress continue at the same time with the constipation, without
our being authorized to impute such symptoms to a violent inflam-
mation of the  peritoneum or  some other  viscus, and  should there be 
278
NEW ELEMENTS OF  OPERATIVE SURGERY.
 no reason to suppose that an infusion of intestinal matter has taken
 place, we  are justified in believing that the strangulation has  not
 ceased, but from having  been external has now merely become in-
 ternal.   The first indication then is to reproduce the hernia; we must
 then make the patient cough and move, and exert himself.  In case
 this does not succeed, the finger  is  to  be introduced through  the
 ring into the abdomen,  in order to  ascertain the state of things as
 correctly as possible.   Should the surgeon clearly recognize the in-
 testinal noose, and find it tense, fixed or immovable, he will endeavor
 to seize it with the dressing-forceps in order to bring it to the outside.
 Should  it appear to him that the constriction has been caused by a
 bridle, ring or any lamella whatever, he should proceed to divide the
 same by means  of the scissors  or curved bistoury  guided on  the
 finger.  If the finger cannot reach the parts, or conveys  only con-
 fused notions in  regard to their  arrangement, we should proceed to
 examine carefully the neighborhood of the wound, in  order to ascer-
 tain  if the organs contained in the belly  do not form a projection
 there, or a  sort  of tumor which  is  perceptible through  the skin.
 There can be no  doubt that under such circumstances it would be
necessary, as a dernier resource, to enlarge the incision at the ring
liberally, and to penetrate to the point where the strangulated organs
are situated, in such manner as to lay them bare completely,  and to
be enabled  to disentangle them and to give them full liberty to
spread out in the abdomen.

                § III.—Internal Strangulations.

  An internal strangulation co-existing with an external hernia may
 oe very difficult of recognition.   A woman 42 years of age, affected
with an omphalocele and laboring under symptoms of strangulation,
was  received in the Hospital of the Faculty, in the month of March,
 1824, and would have been submitted to the operation for hernia
 had it not been perceived that there was a hard deep-seated tumor
 which was situated in her right iliac fossa.  This tumor opened itself
 upon the outside, and was formed by the caecum, which was filled
 with a mass of stercoral matter !  Another woman 49 years of ao-e
 received in the same  hospital, in  the month of July, 1825, had been
 vomiting for the space of 24 hours, with the impossibility of  ob-
 taining  any  alvine evacuation's.  The  belly was  distended and
 painful,  and the  pulse small, hard,  somewhat frequent,  &c. ;  at  the
 same time there existed a crural hernia.  On opening the dead body
 I found  the commencement of the  rectum  transformed into a larda-
 ceous tissue, and completely shut up.   The  hernia had suffered in
 no respect.  In another case, that of a man I operated for strangu-
 lated hernia; the accidents  continued, and I was  on the point  of
 operating for the hernia,  which he had on  the  other side.   After
 death we found  that the intestine, which had become twisted upon
 itself, was  situated within  the  belly in  an  infundibulum  of  the    •
 epiploon.   A patient operated  upon in my presence by M. Michon,
 presented a somewhat similar  case.   Any  polypous, fibrous,  or
 cancerous tumor  of the intestine, should it have acquired  a certain
 size, would produce the same  accidents.   A man who had been a 
                    HERNIOTOMY  OR KELOTOMY.                279

long time in the Hospital of Tours, for vomitings and a constipa-
tion which would yield to nothing, finally died.   The small intestine,
which was greatly dilated above,  was shut  up at its middle portion
by a cylindrical mass more than  a  foot long, partly free and in part
adherent, and which had been  produced by an  ancient degenerate
invagination.  If the hernia which this man had formerly had, had
still existed, the accidents noticed  during his life might possibly have
been attributed to it.
  Numerous examples of this kind are found in scientific works.   A
patient who was sent to me in the month of October, 1881, from the
service of M. Andral, presented to me one of the  most remarkable
examples of this description; the memoir  of Hevin proves, at the
same time, that the different descriptions of  invagination may pro-
duce the same assemblage of  symptoms.  It  may also  happen that
such accidents arise from a spiral torsion of a noose of  the small in-
testine upon the mesentery, or  by its becoming flattened against the
spine, as was proved by the death of Chopart; from a circular con-
traction on a portion of the organ which has been returned into the
belly, after having been for a long time lodged in a hernial opening,
as in the case related by Ritsch ;  or from the neck of the sac, after
it has been  returned into the belly with  the  hernia, continuing  to
strangulate the intestine, as  is seen  in the cases of Le Dran, Ar-
nauld, &c.;  and more frequently still from  the noose of the intestine
becoming entangled to such degree as to be strangulated by passing
through certain rents or below certain bridles  or appendages of the
abdominal organs.   M. Berard has  seen it in this manner become
lodged in  the anterior mediastinum, by detaching the xiphoidean
fibres from those of the diaphragm ; and also it has been in  many in-
stances seen introduced into one or the other of  the thoracic cavities
through the body of the diaphragm itself; through a rent of the epi-
ploon, as has been seen  by Arnaud; of one in the  mesentery,  as
mentioned by Saucerotte and M. Bouking, (Gaz. Med., 1838, p. 109 ;)
through  the  hiatus of Winslow,  and a laceration of the transverse
mesocolon, as noticed by M.  Blandin ; between the bladder and the
pubis, (H. Cloquet,  Bull, de la Fac de Med. de Paris, p. 86,) where
an epiploic bridle, adherent to an  inguinal sac retained  it in a state
of strangulation; under  the  caecal  appendix, which latter had be-
come adherent at its point, on some one or  other portion of the cav-
ity  of the abdomen ; under an accidental diverticulum of the intes-
tine ;  under an epiploic arcade, connected with the spine on the one
hand, and with the upper strait  of the pelvis on the  other, as has
been seen by M. Bonnet; under an enormous  bridle in the  form of a
T, the horizontal  branch  of which extended  from the  liver to the
left side,  and the vertical  portion to  the right iliac fossa, as I have
noticed in two instances; finally, under the thousand forms  of bri-
dles or cords, that diseases or certain accidents may give rise to the
formation of in the interior of the belly.  Strangulation  produced by
these various causes, differing after  all from hernial  strangulation
only in having its seat in the  interior of the splanchnic  cavities, may
consequently readily lead to error in patients  who have at  the same
time a visible rupture externally.   It may, nevertheless, in the ma-
 jority of cases be distinguished  by noticing  the point from whence 
280
NEW ELEMENTS OF  OPERATIVE SURGERY.
 the  pains originate and their direction, and by comparing the con-
 dition of the tumor with that  of the  belly, and vice versa.   When
 this strangulation  exists separately, there is scarcely any room for
 deception, but the question then arises to determine its species, and to
 ascertain if surgical art can afford any relief.  If the affection has su-
 pervened suddenly, in consequence oV an effort made, or any kind of
 violence; if the patient  has been conscious of feeling  a laceration,
 accompanied with a crackling noise, and with a pain, which from one
 determinate point  has extended over the  rest of the belly;  if  from
 this moment vomiting of alimentary, mucous and afterwards sterco-
 ral matters, have continued to take place,  at the same time that it has
 been impossible to  procure alvine evacuations, and that the ordinary
 symptoms of a  violent peritonitis are wanting, it would be difficult
 not to believe in the existence of an internal strangulation.
  A. Internal remedies.—Three classes of remedies have been pro-
 posed to relieve accidents of this kind.  The ancients, who were
 fond of believing  in  the existence of invaginations and the twisting
of the alimentary tubes, had great confidence in quicksilver, balls of
lead, purgatives, &c.   They hoped by means of such heavy and ac-
tive substances,  to act mechanically on the intestines, and  to compel
them to  disentangle  themselves by  means of  sudden  movements.
MM. Balluci, Bellini, and  Ribell, have  also  in  our days adduced
examples  in favor of quicksilver.  In recent  and simple volvulus,
such means might in  some cases be followed  by success ; a patient
who by the advice of M. Vogel, (Arch. Gen. de Alid., t. I., p. 450,)
had swallowed  quite  a large quantity of  crude  mercury, evacuated
twenty-two inches of small intestine, the nature of which was es-
tablished by M. de Rapp.   Forty-three cases of this kind have been
 collected by M. W. Thompson, (Encyclog. des Sc Med., 1839, p.
 221 ;) but there  is no  person who would not dread their employment
 in a case of internal strangulation properly so called.   For my own
 part I should not dare to have recourse to them.
  B. Local and general bleedings, cataplasms and opiates, suitable
 for moderating the inflammation and  assuaging the pain, have no
 influence whatever on the kind of constriction in which the intestine
 is implicated.   The only advantage they have is that of favoring the
 efforts of the system, or the process by means of which it has in certain
 cases been so fortunate as to re-establish  the continuity of the intes-
 tine without destroying its permeability.   The invaginated portion of
 the intestine  may in  fact,  after a-greater or less length of time, and
 accidents more  or less severe, become detached by the rupture of its
 neck or root, whether it has been attacked by gangrene, or whether
 this separation  takes place by the progress of a simple eliminative
 ulceration.  In  such  cases the mortified mass, having become free, is
 ultimately expelled outwardly.  The whole of the caecum,  and  a
 large  portion of the sigmoid flexure of the colon have been seen to
 be discharged in this manner, numerous examples of which are con-
 tained in the memoir of He" vin.   MM. Rigal and Bounial (Ibid.) have
 seen as much as 30 inches of small intestine evacuated by this process.
 Cases that  are nearly similar  have  been related by  MM. Mallet,
 Baillie. Lobstein, La Coste, Boucher,  Gaultier de Claubry, &c.
   C. Gastrotomy.—It is readily understood,  moreover, that a ter- 
HERNIOTOMY OR KELOTOMY.                281
mination like  this can only take place in cases of invagination, and
that for the relief of an actual strangulation we cannot count on the
resources of the system.  Gastrotomy then presents itself as our last
refuge.   Up  to  the  present time but few persons have ventured to
perform it, and experience, so to speak, is silent on this subject.  We
cannot,  in  fact,  place any confidence  in  the  history of a certain
Baroness de Lanti mentioned by Bonet,  and who, according to the
authority of an ecclesiastic, had been cured of an iliac passion by an
incision into  the lower belly.  Though  the case  in which Nuck re-
commended the belly to  be  opened  in order to reach and untie the
intestines may  be  somewhat more authentic,  and  that M. Fusch
(Arch.  Gin. de Med., t. IX., p. 118,)  has published a case of radical
cure by gastrotomy performed for an invagination, we cannot, never-
theless, but with extreme caution,  place reliance upon  so  small  a
number of facts.  M. Pring, (S. Cooper, Diet, of Surg., 7th edit.,
p. 311,)  desirous of affording relief to a lady whose  rectum had be-
come obliterated by scirrhosities, laid  open the sigmoid flexure of the
colon, established an  artificial anus  there,  and in this manner pro-
longed  the life of the patient six months; but M. Monod. (Gaz. Mid.,
1838, p. 667,) having performed gastrotomy in a woman twenty-five
years of age for supposed ileus, saw death supervene two days after,
and found that in place of an ileus the case was nothing more than a
simple  coarctation  above the caecum.   If it should  happen that we
had arrived almost to a positive certainty of the existence either of a
recent invagination or of a strangulation, and that the locality of the
disease  was well ascertained, we should, in my opinion, venture to *
perform gastrotomy, which was already in use at the time of Praxa-
goras, who united the wound of the belly immediately, by means of
the suture.  Dupuytren, who made trial of it in one  instance, would
probably have succeeded, he says, if he had been allowed to incise as
he wished upon  the side of the  belly where the pain  was situated, in
place of incising on the  linea alba  as he did, in conformity to the
advice of the consulting surgeons.   A case noticed at the hospital of
St. Antoine, and the facts which I have since collected at La Charite,
prove also that it is in some cases possible to designate, with sufficient
precision during life, the actual seat  of  the strangulation.   The pa-
tient should be laid upon his back, in  the same way as for the opera-
tion of  ordinary hernia.   The incision, which should be rather semi-
lunar than straight, should be made very near the strangulation.  If
we are  not sure  of the seat of this last,  the incision  should be made
outside  of the recti muscles.   We should then seek  for the  diseased
part by  means of the fingers.   In case of invagination we should, in
order to remove it, only have to make traction upon  the two ends of
the intestine  in  an inverse direction, and then immediately replace
the whole in the peritoneal cavity.   If it were a strangulation the
finger might undoubtedly succeed in reaching and isolating it, in such
manner as to divide the constricting band or circle without danger
by means of a bistoury.  A female  patient who was sent to me by
M. Donne, and  who died at the Clinique, might possibly have been
operated upon in this manner.
  D.  After the taxis.—Another kind  of internal strangulation, viz.:
that which  persists  after the  forced reduction  of a  hernia, also
  vol. iu.                     36 
282
NEW ELEMENTS  OF OPERATIVE SURGERY.
  requires to be mentioned.   M. Delmas mentions a case in which the
  organs had  become lodged  in  this manner in the tissues of the
  muscles themselves.   They may also pass under a bridle or through
  a rent, in the same manner as when we wish to reduce them after
  having opened the sac, and as I have mentioned further back.  It is
  unfortunately a thing too common to  see these reductions in mass
  under the influence of the taxis, incapable of preventing  the accidents
  from marching progressively forward.   There  arc few authors who
  have not mentioned  instances of this kind, and we still daily meet
  with them in practice.   The  first thing to be done is  to  make the
  hernia protrude again.   If nothing should present itself at the ring,
  the surgeon would be censurable if  he delayed  too long a time and
  did not perform the operation immediately.  He knows  that a hernial
  tumor existed ; that after having given rise to accidents or remained
  a long time outside, it has disappeared under the influence of extra-
  neous  efforts; the opening which had  given a  passage to  it is free,
  readily admits the  extremity of the  finger,  quite frequently even
  exhibits  a kind of depression or cul de sac, or seems  to  be  drawn
  towards the  interior by some bridle or some  adherent membrane;
  and  sometimes also the finger directed into this depression is enabled
  to feel an intestinal tumor which has been imperfectly  reduced.  In
  a case like this we incise the  soft parts in the same way as for stran-
  gulated hernia, and we arrive by degrees into its interior.   If the sac
  may be reached, it rarely happens that the operator is not enabled to
# come down upon the seat of the disease.  Dupuytren, who had been
  frequently called  upon to relieve this species of strangulation, and
  who had seen a great number of these cases at the Hotel Dieu, makes
  the remark that after having in vain endeavored to bring the viscera
  to the exterior, we have the resource still left of largely incising the
  ring in the direction in which  there are no vessels, and of arriving by
  this  means into the belly.

                  § VII.—Hernia with Gangrene.

    A.  When the tumor is entire.—When the gangrene of a hernia is
  recognized at first view, the division of the tissues  does not  require
  the  same precautions as in the  ordinary operation.   The incisions
  may in fact penetrate, without any impropriety, into the  intestine with
  the  first cut.  If  the gangrene comprises the whole tumor, and the
  hernia be of large size, we should,  after  having made  several deep
  incisions, remove all its mortified portions.  We might nevertheless
  confine ourselves to the incision of the intestinal noose and wait for
  the  sloughing of the tissues.  Quite a number of facts show that  the
  system, under such  circumstances, readily succeeds  in effecting a
  complete cure.   J. L. Petit,  travelling on one  occasion by post  in
  Germany, stopped at an inn, and was immediately struck by an odor
  of gangrene.  They showed him, in a neighboring room, a man who
  was suffering with symptoms of hernia with mortification.  Suppos-
  ing  the man would die he merely made some incisions into the tumor,
  which immediately  discharged  an abundant  quantity of matters.'
  Upon his return, twenty-eight days after, J. L. Petit learned,  not
  without astonishment, that his patient had  recovered perfectly, and 
HERNIOTOMY OR KELOTOMY.
283
was cured without a stercoral fistula. Having gone on another occa-
sion to Ferte-sous-Jouarre and lost his way in the night,  he asked
the road  at a house where he perceived a light.   The woman told
him her husband was at the point of death, and entreated him to come
in.   This also was a strangulated hernia, which J. L. Petit confined
himself to opening and cleansing, recommending  not to adopt any
other measures, as he considered that  this patient also would not
survive.  The cure however did take place, and it was the individual
himself who came to inform the surgeon of it some time after.
  B.  When the  tumor is  opened.—Nevertheless we cannot dispute
that it is better to liberate the tumor, by means of the scissors or bis-
toury, of  everything it may contain that is evidently mortified.  In
other respects there is no reason why we  should proceed otherwise
than if the intestine alone was gangrenous, and that we did not recog-
nize the gangrene until after the opening of the sac.   In this last case
the gangrene may occupy only the most projecting part of the stran-
gulated noose, as it may have its seat in the interior of the ring itself
and upon the parts which are directly acted upon by the constriction.
  I. To open largely into the intestine.—Many methods have been
recommended in the event of this accident.  One of the  most an-
cient consists in  opening largely into the intestine in order to make a
free passage for  the matters.  In proceeding in this manner, we have
two things to  apprehend:  1st, that the constriction may persist to
such degree as to present difficulties to the passage of the substances
contained in the alimentary tube *, 2d,  that we almost unavoidably
establish an artificial anus.  To these objections some persons have
replied, that the lower portion of the intestine from no longer receiv-
ing any matters, shrinks; that the portion which corresponds to the
stomach being the  one which alone continues to receive the digestive
substances, ought  to be  sufficiently large  in the hernial opening to
fulfill  in that part without danger  the functions of  an abnormal anus.
On  the other hand, experience  demonstrates that this  mode  of pro-
cedure has frequently been followed in quite a short time by a radi-
cal  cure.  The two examples just cited are an  evidence of it, and J.
L. Petit relates others which are  no less remarkable.  This surgeon
being on his way to Flanders, was sent for on the road at Douay, in
order to give  his opinion respecting a hernial tumor which he could
not reduce and which was strangulated.  A charlatan, whose opinion
had been concurred in by the relations of the patient, maintained
that this tumor was an abscess  and that it was necessary to  open it.
J. L.  Petit informed them that this might be followed by serious
accidents, and that there would at least  result from it a stercoral
fistula.  Upon his return he was informed that the  patient had been
perfectly  restored.  He  furthermore  learned that the  charlatan
opened in this manner all strangulated hernias, and that  in the en-
virons of Douai and Cambrai he had  thus operated upon a great
number of persons.  A student of medicine declared to me  that his
father, who was a surgeon  in one of the  provinces, had been led
from experience  to adopt a similar method, and that he had already
employed it ten or twelve times with success, whether the strangu-
lated  hernia was or was  not accompanied with gangrene.  When
we  recollect that cases of artificial anus which have existed a long 
284
NEW ELEMENTS OF OPERATIVE  SURGERY
 time have  ultimately disappeared spontaneously,  though the  two
 ends of the  intestine had  become  adherent to  and consolidated in
 the ring, and that a considerable  portion of the gut had  been re-
 moved, such results as those above must soon lose their marvellous
 character.   The resiliency (ressort) of the mesentery and the natu-
 ral movements of the organs contained in the belly, must necessarily
 constantly tend to  draw towards them the portion of gut which has
 escaped into the hernia.   Little  by little the two ends of the intes-
 tine succeed in reaching the posterior surface of the ring and in ap-
 proximating to each other; their openings ultimately become united
 and the matters pass into  the  lower portion of the gut in place of
 escaping by the wound,  which latter moreover as it contracts, pre-
 sents to them a greater and greater degree of resistance.
   II.  To divide the ring.—All authors  however do not  concur in
 this mode of considering the  subject.    Scarpa recommends that
 after having opened the intestine, if there should be  much stran-
 gulation we should divide the ring.  Without this precaution the
 matters accumulated behind it  would experience, he says, too much
 difficulty in escaping, and would  give rise to a dangerous inflamma-
 tion even in supposing that they did not keep up the symptoms of
 strangulation.  What danger would there be after all, in proceeding
 in this manner 1  The adhesions which he admits upon the limits of
 the gangrene must give entire confidence.  Even though we should
 be obliged to incise the intestine  from within outwards, at the same
 time with the neck  of the sac and the fibrous ring which surrounds it,
 we should not, according to him, have any  reason to apprehend an effu-
 sion into the peritoneal cavity.   Dupuytren, who has taken  ground
■ against this doctrine, maintains, when the gangrene has reached into
 the ring, that the borders of the hernial opening are usually mortified,
 and that after the intestine has  been once laid open the strangulation
 must soon disappear of itself, and consequently render all kinds of
 debridement unnecessary.   He thinks, moreover, that the adhesions
 mentioned by Scarpa are far from being constant around the whole
 circumference of the intestine, and that if the incision of the alimen-
 tary tube was extended to  behind the ring, they would not present a
 sufficient obstacle to the effusion of the matters.
   It is  certainly incorrect to say that gangrene is  never  developed
 without being preceded by adhesions between the neighboring serous
 surfaces.   The opening  of the dead body in individuals  who have
 died  in consequence of strangulated hernia, has satisfied me that
 Scarpa had  singularly exaggerated the  importance of this  morbid
 condition, and that he  was deceived as  to its  frequency and the ra-
 pidity with which these adhesions are developed.  That these adhe-
 sions, in fine, are sometimes restricted to such narrow limits, that it
 would  be  difficult  not to  go beyond them in dividing the  hernial
 stricture  through  the intestine.  On  the other  hand, it appears to
 me that the mortification of the neck of  the sac, and  of the borders
 of the  ring, is much less  common than MM.  Corbin and  Caillard
 represent Dupuytren to have stated it, and that if we had to count
 upon this  in order to put a termination to the strangulation, we
 should  have frequent cause to  regret it.  For  example, it does not
 take place when it is the free portion  of  the hernia which is  morti- 
HERNIOTOMY OR KELOTOMY.
285
fied.  I will add, that if we do not divide the stricture, the intestine
which is inflamed behind the portion destroyed, usually becomes the
seat of  considerable tumefaction, which reaches its three tunics, and
especially its mucous lining; and that this tumefaction, arrested out-
side by the  constricting circle, extends almost exclusively upon the
inner side, in such manner as to produce in some instances  almost an
entire obliteration of the intestinal opening.   This is a result which I
saw take place in a woman operated upon for a hernia with gan-
grene at the hospital of Perfectionnement, in 1824,  and who died on
the following day.   The same result also has happened several times
in other hospitals of Paris.  In conclusion, if, after having opened the
intestine, the  matters which it contains either in the hernia or in the
belly, freely escape, and if the constriction of the ring is inconsiderable,
we may dispense with dividing it.  If, on the contrary, the finger in-
serted into the strangulated portion penetrates and  passes through it
with difficulty, prudence, in my opinion, suggests that an opening of.
this description should be enlarged.  If the instrument can  be readi-
ly glided between  the viscera and the sac  without exposing  to  the
risk of  destroying  the adhesions  which might  possibly exist behind,
the debridement is to be performed as in the usual  operation.   If a
contrary state of things exists, the bistoury is to be directed into
the  interior of the intestine itself, to incise  from  the centre  to  the
circumference, and in  one or more  directions, the  orifice through
which the matters are  to pass.   In  reflecting upon the natural ar-
rangement of the parts, it will be seen moreover that the incisions in
such cases incur less risk than would be supposed, of producing an
infusion into the peritoneal cavity.  This  effusion would not in fact
have to be dreaded, unless the incision was  carried beyond the pos-
terior orifice of the ring, and consequently  beyond  the place  where
the strangulation  is situated, the constriction under such circumstan-
ces being almost constantly somewhat nearer to the external aponeu-
rosis than to the fascia  propria, or the peritoneum.   This fact per-
haps might reconcile the ideas of Dupuytren with the practice of
Scarpa.  If we have not divided  the  stricture; if at the  expiration
of a few hours the colics still continue; and  if in removing the dress-
ing we perceive that the matters  escape with difficulty, it  is in our
power, moreover, to introduce into the upper end of the intestine a fe-
male catheter, a silver  canula, or what is  better still, a large gum
elastic tube, and thus procure immediate relief from this  difficulty;
but if in spite of this the engorgement of the tissues and the narrow-
ness of the ring present  impediments  to the  re-establishment  of the
functions, we must divide the stricture, as we might have done at the
moment  of the operation.  Since this part of the work was printed,
in 1832,  I have frequently, from  many practitioners having carried
the prolonged taxis to  an abuse,  had occasion to treat in  this man-
ner hernias  accompanied with gangrene, and  it is now a practice
which I have definitively adopted.

        § VIII.—Hernias with Perforation of the Intestine.

   Up to this point we have supposed that the parts  were left in their
place; but a great number of practitioners consider that we should, 
286
^TEW  ELEMENTS OF OPERATIVE SURGERY.
in order to satisfy ourselves of the extent of the gangrene, cause  a
certain portion of the  intestine which was not contained in the her-
nia, to be brought through the ring and drawn to the outside;  they
recommend also that we should then excise every portion of it which
is mortified,  by dividing  through the living  part; that we should
reduce the sound parts in such manner as to leave nothing more in
the wound than the opening or the openings which have been made,
or that we should immediately endeavor to unite the two ends of the
intestinal  noose  by means  of the suture; from  hence  arises many
operations applicable to perforations which are caused by gangrene,
as well as to those which result from ulcers, wounds, &c.
  A.  Process of Littre'.—After gangrene Littre  proposed  to tie the
inferior end of the intestine, in order to effect its obliteration, then to
attach its  upper end into the  ring in order to establish, in this man-
ner, an artificial anus, which the patient was to retain the rest of his
life.   Louis, who was disposed to adopt the advice of Littre, finds it,
however, attended with a difficulty, viz., to know how to distinguish
the upper  from  the lower  portion of the alimentary tube, to avoid
which he  recommends that we  should  administer to  the patient  a
small  quantity of syrup of chicory, which, being evacuated at the
expiration of a few hours, indicates  by  its  green color in which
direction lies the stomach and in which the rectum.   This is an in-
genious suggestion, but we  are rarely obliged to have recourse to it.
After  the  division of the intestine its inferior  end  almost always be-
comes contracted, and  in a short time reduced to the  size of a large
cord; while the other usually  preserves its primitive dimensions, and
moreover, continues to give egress  to the matters.   As the process
of Littre  has the effect of establishing  a disgusting infirmity, it has
necessarily been proscribed, and at the present day is  not worthy of
the slightest attention.
  B.  Lapeyronie has proposed one which is  more simple and more
rational.  This surgeon passes  behind  the division a  double thread
through a fold of the mesentery, and  after having pushed back the
two ends  of the intestine into the ring, makes use of  this  thread  to
prevent their entering the  belly completely, by attaching it at  the
outside upon the dressing  by any mode whatever.   We  obtain by
this means, it is true, an artificial anus, but one which may possibly
close  up spontaneously, or by the aid of art.  Scarpa, who censures
the process of Lapeyronie, recommends, after we have once removed
the gangrenous  portions, that we should leave the  two ends of the
intestine in the wound. The  adhesions they have contracted during
the time the mortification has been going on, are always sufficient,
he says, to prevent them  returning too speedily into  the  belly, and
to constitute a certain  obstacle to any kind of effusion into the peri-
toneal cavity.  According  to him the thread  through  the mesentery
would  be injurious in  more respects than one; in the first place, by
presenting an impediment to the gradual retraction of the parts, and
to  the formation  of the membranous funnel;  secondly, because this
thread, which  must soon  cut through  the mesentery, may, at the
same time, divide certain vessels whose  hemorrhage would be  a
source of apprehension; and in the last place, because this thread,
from  resting against the deep-seated surface of the intestines, may 
HERNIOTOMY OR KELOTOMY.
287
possibly cause there an ulceration or perforation, in the same manner
as a precautionary ligature  may divide the artery around which it
has been placed.  As the apprehensions of Scarpa, however, have not
been concurred in by all surgeons, there are some who have imitated
Layperonie, and who allege that they have had no reason to be dissa-
tisfied  with it.  M. Hervez de Chegoin, (Revue  Med., 1829, t. III.,
p. 517,) among others, published, in 1829, a case of cure in support of
this process.  There would be no difficulty, moreover, in leaving the
thread for the space only of one or two days, if we really had any
apprehension about its presence ; we would have  nothing more to do
than to keep the two  halves apart by attaching  them separately to
the outside, and  after the expiration of a certain  time nothing would
be more  easy than to remove the thread by drawing upon it on one
of its extremities.
  C. Suture.—In following the course which has been  traced out,
the immediate result produced  would be a stercoral fistula or arti-
ficial anus.  The suture has been proposed with a view of prevent-
ing this infirmity, and  to  re-establish immediately the continuity of
the divided tube.  This is  an  indication which numerous  authors
have endeavored to effect by  various means, which M. Steinmetz
(Bull,  de Fir., t. XVII., p. 395,) asserts he has employed in two in-
stances with success, and which, after having been frequently for-
gotten, has again strongly attracted attention in these latter times.
  I. Suture upon a foreign body.—The first idea of approximating
the two ends of the intestines, and of sewing them together, is attri-
buted to  the four masters who united themselves together for com-
mon purposes of charity in relieving  the sick poor of Paris.
  a. The four masters.—These surgeons commenced, it is said, by pro-
curing the windpipe of an animal.   Introducing one extremity of this
tube into the upper end of the divided gut, they inserted the other into
the lower end, and then approximated the ends of the two bleeding cir-
cles, in order to adjust them and keep them in contact by means of seve-
ral points of suture.   Guy de Salicet, who lived before the time of G.
de Chauliac, does not make mention of the animal trachea; but he was
acquainted with  the process of the four masters, and openly censures
it.  " Do  not listen," says he, " to those who tell you before sewing up
gut, that  we must place inside of it a canula of sambouc wood (sam-
buc,) or something else, and then sew up the wounded gut upon this,
for," &c.   And further on :  " It would be  much better to use a por-
tion of gut from any animal, ....  but we must use neither this or
anything else."  Is it, however, quite certain that the ancients on this
subject entertained opinions similar to those held  at the present day 1
Guillaume mentions it only for  incomplete divisions of the intestinal
tube, and expressly states that the others are necessarily  mortal.
  b. There is nothing moreover to show that Guy entertained a dif-
ferent  opinion.  " And if there should be necessity of a suture (of the
parts contained in the belly,)  and that  it would be  advantageous in
the manner that  it is at the bottom of the belly, and in the large guts,
they may be sewed together by the glover's suture.  Some persons,
like Rogier, Gamier and Theodore, place in the gut a canula of elder,
in order to prevent the  cleft from mortifying the suture, others, as
Guillaume has mentioned, introduce  there a portion of the gut of 
288
NEW ELEMENTS  OF OPERATIVE SURGERY.
 some beast, or a portion of the trachea, as the four masters do." The
 above are Guy's own words.
   c. Watson has since recommended a canula  of fish glue.  Some,
 with Scarpa, make mention of a cylinder of tallow.  Sabatier, Ritch,
 Desault, and Chopart, speak of a piece  of playing card besmeared
 with essence of turpentine, or oil  of St. Johns wort, or varnished in
 any manner whatever.
   d. The process of the ancients, however, had attracted so little at-
 tention, that Duverger, who revived it at the  beginning of the last
 century, considered himself its author.  It would not appear, more-
 over, that it had been  frequently made trial of, or that up to the pre-
 sent time it has obtained more than  two  or three cures.  Should it be
 decided upon to make trial of it, it would  be, I  suppose, a matter of
 indifference almost whether we used a very pliant portion of the tra-
 chea of an animal, a  cylinder of glue,  playing card, or  paper, or a
 canula  of gum-elastic.   After having besmeared with  some oily var-
 nish this species of tube or ring, which  necessarily should be some-
 what less in size than the intestine, we should pass through its middle
 portion three or four nooses of thread or silk at a few lines' distance
 from each other, armed at each extremity with a needle, and destined
to form as many points of suture.  Its introduction into the upper end
of the alimentary canal can be attended with very little  difficulty;
but in order to  introduce  it  iirto the  lower  end, this latter  should  be
seized with two forceps, which can make traction upon it in an oppo-
site direction in order  to enlarge its opening.  This being effected, the
extremities of each thread are to be  passed in succession from within
outwards.through the corresponding  end of the intestine, and at the
distance of two or three lines from the wound.   After having knotted
and divided them very near the knot, the whole is to be returned into
the belly; a slight  aperient is to  be administered, and the patient
treated as after the ordinary operation for strangulated hernia.
   e. While the reunion is being accomplished, the threads cut through
the tissues which they embrace, and as soon as this process is effect-
ed) the foreign  body, now become free, descends with the intestinal
matters, and is soon expelled.  In place of four threads, Duverger re-
 commends two only, one  in front, the other behind.   Those of Ritch,
 as they were composed of one string, had the inconvenience of form-
ing a kind of septum in the interior of the card.   Desault had no other
 design  than that of getting rid of this difficulty when he proposed the
 modification which is imputed to him, and  which is not of sufficient
 importance to be described in detail.  A suture  of  this description is
 in the first place very difficult to accomplish; afterwards we should
 have reason to fear that the reunion  would not be  effected in  the in-
 terval between the points of  suture; that  the  threads in  becoming
 liberated, might leave ulcerations, and allow the effusion of some of
 the fluids.  Finally, its dangers are  so formidable  that unless there
 had been conclusive experiments and numerous  facts,  which science
 does not at the present day  possess, we should not  decide on having
 recourse to it, but  in despair of any other means.
   II. Suture  with invagination.—a. Randhor.—Randhor having
 under  treatment a soldier in whom the continuity of the intes-
 tinal tube had been   destroyed,  proposed to  introduce the upper 
HERNIOTOMY OR KELOTOMY.
289
 into the lower  end, to attach them  together  in  this position  by
 means of two points  of  suture,  then to  reduce  them  and leave
 them in. the belly.  His  patient  recovered perfectly.  As he died
 some years after of another affection, Randhor being  thus enabled
 to examine  the  condition of the parts, removed the portion  which
 had been formerly divided, and sent it to Moebius, who took occa-
 sion to show it  to Heister, which latter, upon the strength  of this,
 made experiments of  the  same operation  upon dogs,  but without
 success.  The method of Randhor, which has been eulogized  by
 some,  rejected as impossible  or  dangerous by others, admitted as
 very ingenious by Louis, and  made trial of in  a great number  of
 instances since it has been known, does not appear to have succeed-
 ed but in a very small number of cases.  Boyer performed it in one
 instance and his patient died.   In another case he was not enabled to
 complete the operation.  I have seen it attempted at the hospital  of
 St.  Louis, in a  patient, who also died on the following day.   M.
 Lavielle (Journ.  Gen.  de Mid.A. XLV., p. 176,) and MM. Chemery-
 Have,  Schmidt  and  some others  have,  however, each  related
 an instance  of  cure in its favor.  The first difficulty is  to over-
 come the contraction of the lower end of the intestine.   One of the
 best means to effect this, would be to seize at the same time its two
 principal diameters at  their four extremities, with  the same number
 of forceps or hooks.   In order to  prevent the upper end from filling
 up or becoming  swollen, the assistant would have  nothing  more to
 do than to grasp  it at the  distance of four  or five  inches  from the
 division, and to  hold it properly  compressed, while the surgeon is
 endeavoring to draw it and  adjust it into the opening of the rectal
 portion.  But there is another  obstacle which M.  Richerand, I
 believe, was the  first to point out in a clear and unequivocal manner.
 The researches  of Bichat have shown that mucous membranes  do
 not contract adhesions  with each other; and that adhesive inflamma-
 tion does not usually take  place except between cellular  surfaces.
 Now, in the  invagination, after the manner of Randhor,  it is the
 peritoneal covering of the  upper end of the intestine, which is placed
 in contact  with  the  mucous  membrane  of the - other.  If the law
 established by Bichat is true, and the remark of M. Richerand well
 founded, the agglutination of the  two ends of the  intestine  by this
 method would be impossible.   Therefore it had been almost entirely
 proscribed  when M. Raybard (Mem.  sur les Anus Artific, 1827,)
 undertook to bring it again into repute, and to show that it  is pre-
 ferable to the one which it has recently been proposed  to substitute
 in its place.
  b. Process of M.  Raybard.—In support of his assertions, this
 surgeon relates a number of his experiments upon living animals and
 facts in  pathological  anatomy collected on man.   M. Raybard, like
 Randhor, recommends  that we should  first incise the mesentery in a
 direction parallel  to the concavity of the intestine, and to the extent
 of a few lines.   Afterwards he passes a little  above the wound a
thread, one end of which remains within  the canal, while the other
hangs outside.  According to him, two nooses thus  adjusted will  be
found sufficient, that is, one on each extremity of the antero-posterior
diameter of the diseased gut.   By the aid also  of a needle,*we are
  vol. in.                   37 
290
NEW ELEMENTS OF OPERATIVE SURGERY.
 enabled to pass the inner extremity of each thread from within out-
 wards, and through the lower end of the intestine, in order to inva-
 ginate the two portions methodically, and to terminate, by fastening
 each point of suture by means of a knot.   M. Raybard maintains
 that his process is at  once more certain, more easy, and infinitely
 less dangerous than that which has been  proposed by M. Jobert; I
 have not,  however, learned that it has  yet been applied to man.
   III.  Suture  with contact of serous surfaces.—Experiments  which
 were already  ancient, might have been  adduced in support  of the
 ideas of M. Richerand.   MM. Schmidt, Thompson,  and Travers,
 had remarked  the singular phenomenon, viz. that if we apply a thread
 around  a  small perforation of the intestine, it soon sinks into it as
 into a  depression,  in such manner as to be approximated gradually
 to the interior  of the canal, and to become entirely free there,  at the
 same time that the serous membrane or surface is approximated pos-
 teriorly, and blended with a layer of plastic lymph as if intended to fill
 up the opening which but for that would have been left.  Still more,
 M.  Travers has found that if we strangulate the entire calibre  of the
 alimentary canal,  the  peritoneum of the upper portion adheres so
rapidly to  that of the iower, that the septum formed  by this  stran-
gulation soon becomes gangrenous, and is detached and drawn in the
direction of the rectum in such manner that the tube ultimately be-
comes perfectly re-established.   In France  the labors of Dupuytren
on  the subject of artificial anus, had  also already corroborated the
same facts, and shown with what facility and promptitude two por-
 tions of the external surface of the intestine will agglutinate when
 they are kept in contact.
  a. Process of M. Jobert.—From these various facts M. Jobert con-
 structed a method which appeared at first to promise important results.
 This surgeon commences by turning in the orifice of the lower end of
 the intestine; he then employs the suture  in the manner of Randhor,
 and by this mode succeeds in bringing the two ends of the intestine into
 contact upon their serous surface only.  Two threads were found by
 him to  be sufficient;  he does not knot them, but attaches them out-
 side, in  order to remove them after the expiration of  a few days.   In
 his experiments made upon cats and dogs  he has, he  says, succeeded
 perfectly.   But this mode of invagination, which  would not appear
 to  be attended with much less difficulty than that of Randhor, pre-
 sents, at first sight, the advantage only of placing in contact two por-
 tions of the peritoneum, instead of applying the peritoneum upon a
 mucous membrane, as  in the ancient process.  It has not yet,  more-
 over, been made trial of upon living man.
   b. Process of M. Denans.—M. Denans, a surgeon of Marseilles,
 proposed  about the same  time  another mode of invagination.  For
 this purpose he required three  small hollow metallic cylinders.  He
 placed one in each end of  the intestine, which latter  he turned or in-
 vaginated within  them.   The third  cylinder, which was somewhat
 smaller than the two others, was to be introduced  into the one above
 and then into that below, in such manner as to act as  a rod, axis or
 support to both.   A noose of thread embraces them and secures all
 the three on  two different points of the intestinal circle.  The ends
 of the  suture are divided very near the peritoneum, and the  whole 
                   HERNIOTOMY  OR KELOTOMY.                 291

returned and left in the belly.   The agglutination of the  parts is
soon accomplished.   Everything which is pressed between the three
cylinders soon becomes gangrenous and is detatched, and these foreign
bodies have then only to descend and pass out with the evacuations.
M.  P. Guersent has corroborated  the  assertions of M.  Denans by
exhibiting an intestinal  noose, the  ends of which had been brought
into contact  by the process with the cylinders, and had perfectly
cicatrized.   M. Denans, (Note a  VAcad. de Med., 1838,) by simplify-
ing his process still more, uses only at the present day the three cy-
linders, which incase themselves  so accurately that he does not find
it necessary to make use of the suture.
  c Process of M.  Lembert.—M. Lembert in 1825 proposed another
mode of bringing the serous surfaces into contact.  He passes with
an ordinary needle  as many nooses of thread  as he wishes to make
points of suture, first through the thickness of  the walls of the upper
end of the intestine and afterwards through those of the lower end.
The point of this needle is introduced upon the external surface of
the gut at  the distance of two or  three lines from the wound ; he
causes it to make its way through the tissues as  far down as to the
mucous membrane ; brings it out at one or two lines' distance from its
place of entrance, and succeeds in this manner in adjusting his noose
of thread ;  applies  his  needle with the same precautions upon the
external surface and into the tissue of the rectal end of the intestine;
introduces  successively and  in  the  same  manner  the  number of
threads which he judges advisable, and afterwards has nothing further
to do than to knot them in order to complete the suture.   In making
traction upon nooses of this kind  we compel the lips of the wound to
become reversed upon  their internal surface, to form a valve or
projecting border in the interior,  and to produce at the same time an
exact approximation and direct  contact of the outer surface of the
two ends of the intestines whose  continuity we wish to re-establish.
  d. These three processes have the same object in view, viz:  that
of the adossement of the two serous surfaces.  That of M. Denans
appears to promise more  certainty and to be  attended with  less
danger than the two others, in  this  respect,  that it  cannot  be  dis-
arranged.  Who, however, would venture to leave the intestine in
this manner in the belly ?  Who will guarantee  that these  metallic
tubes will not perforate the intestine ? In operating after the manner
of M. Jobert we incur the risk of the threads becoming relaxed, and
some points  in  the circumference of the intestine may continue
ununited and allow of an effusion.  The modification of M. Lembert is
apparently more simple and easy; it  does not require either the pre-
vious inversion nor  the invagination,  but it appears to incur to a still
greater degree than the preceding, the risk of leaving  between the
points of suture some interval through which the matters might possi-
bly escape.
  e. The Author.—If however I was disposed to make use  of it, I
should prefer employing the whip suture ; that is to say, that I would
pass  the needle obliquely  from  above downwards, from the upper
end to the  outer surface of the lower end; return afterwards above
to the first end at a line or two from the point where I left it, then
come back on the second and return again  to the first, and  so on in 
292
NEW ELEMENTS OF OPERATIVE SURGERY.
 succession until I had passed around the whole circumference of the
 intestine.  To complete the operation there would be nothing more
 to do than to  make traction  in  an inverse direction  upon the two
 ends of the thread, one of which would be at the origin and the other
 at the termination of the suture.  If these simple tractions would not
 suffice to cause the  reversion of the lips of the wound and to  bring
 the peritoneum in contact with itself, the extremity of a sound would
 effect this purpose.  After making a double knot the operation would
 be immediately completed.  The two extremities of  the thread, 01
 either one of them moreover, would serve for attaching the intestine
 behind the ring, upon  the supposition that we did  not  wish to return
 it into the belly; and no knot in that case would be required.
  /.  Upon a rigid examination, would prudence authorize  us in
 depending  upon such resources, which  would necessarily result in
 death if they failed in effecting their object ?  Would we be justifiable
 in exposing in this manner the life of  a patient, when by establishing
 an artificial anus we are almost  certain of being enabled to effect a
 cure at a later period ?  I have used  upon dogs the process of M.
 Jobert and that of M. Lembert, modified  in the manner  I have just
 described.  Whether it be  that  I did not take all the  precautions
necessary, or that I did not possess  all the  experience  required in
such experiments, I am compelled to confess that in two cases out of
six the matters were  effused into the  peritoneal cavity, causmg
thereby the death of the animals.  I will also add that in the four others
two only were  perfectly cured, while  in the third  and fourth  there
remained an aperture through which  mucosities made their escape,
and around which  there were  no  adhesions  or  false membranes,
which cases would not have been very encouraging for  the result.
I was also desirous of repeating the experiments of M. Travers, and
the result was that  in  two dogs, which  were the only instances  in
which I  made  trial of this process,  the strangulated  intestine was
 ruptured, and was  found completely divided alter the death of the
 animal, which took place on the  next  day but one.
  g. M. Choisy, (These, No. 322, Paris, 1837,) making  trial of the
 trachea of  an animal, after  having introduced  it into the upper end
 and attached it there by means of a whip suture, brought the thread
 from within outwards through the lower end, which he  brought up
 by this means before strangulating it  circularly, upon the  tube intro-
 duced.   Though these experiments of the author may have succeed-
 ed upon animals, they  do not appear to be in my opinion  sufficiently
 conclusive to justify the application of his  process, which has more-
 over been still  farther modified by MM. A. Thomson, Amussat and
 Philippe, upon living man.
   h. Priority.—There still remains another question to be decided,
 which is that of priority.  M. Jobert (Arch. Gen.  de Med., t. IV., p.
 73 or 71) has  claimed this honor; but M.  Faure (Arch. Gin.  de
 Aled., &c, t. X., p. 474) alleges that when he was a pupil of the Hos-
 pital of St. Louis, he had proposed before the year 1820, the adosse-
 ment of serous surfaces in intestinal wounds. M. Denans (Ibid., t. XII.,
 p. 618; Soc. Med. de Marseilles, 1826 ;  Journ. des Prog., t. III., p.
 250 ; Bull, de Fer., t. X., p. 90) also mentions that the  suggestion of
 his process is disconnected with the researches of M. Jobert, and M. 
HERNIOTOMY OR KELOTOMY.
293
 Lembert, (Ibid,, t.  X., p.  318; Bull, de Fer., t.  IX., p. 325,) on his
 side maintains that he published his in the year 1825.  To determine
 who is completely right or entirely in the wrong in the midst of all
 these pretensions, would doubtless be a difficult matter.   The follow-
 ing is  what appears to me to be probable.
   M. Denans began his experiments in 1823, but they were not an-
 nounced until March, 1824,  and the Archives for January of the
 same year, contain a description of the process of M. Jobert.  The
 idea of placing the peritoneum  in contact with itself in order  to
 bring  about the reunion  of  intestinal  wounds  is derived  from the
 labors of Bichat, the assertions of M. Richerand, the observations of
 Dupuytren, and the experiments which were made at the same time
 in England and in  America.   M. Jobert, transforming  this sugges-
 tion into a  principle, has, like M.  Denans, a little sooner or a little
 later, or at the same time with M.  Denans, invented a peculiar pro-
 cess to test its application. Setting out also from this point, M. Lem-
 bert, who  did not  communicate  his memoir to the  Academy until
 1825,  has proposed another  mode of effecting the same object, and
 this is the  one that M. J. Cloquet appears to have made trial of a
 short time after, upon the  man in  whom he had the misfortune to cut
 into the intestine while  operating for a strangulated hernia.   Such,
 if I am not deceived, is a true statement of the case.
   i. Appreciation.—The  important point to be ascertained at the
 present time would be,  to what extent  it should be retained in prac-
 tice.   In my view the most rational process is that of M. Lembert,
 and this is the one  to which we must necessarily ultimately give the
 preference, should  experience ever  confirm the theoretical principles
 which have suggested it.   M. Dieffenbach, (Arch. Gen. de Med., 3e
 serie, t. I., p. 314,)  who operated by this process, after having ex-
 cised a gangrened noose of the intestine, supposed that  he  had suc-
 ceeded, but the patient died at the expiration of a few weeks.  Two
 points  of the suture were  still suppurating.  We must moreover not
 forget  that pure and simple invagination, in the manner proposed by
 Randhor or as modified by M. Raybard, has to be submitted to new
 experiments upon living animals, before being definitively proscribed
 or yielding its place to the process  either of M. Jobert, M. Denans
 or M. Lembert.
  D. If the mortification were limited to the peritoneal tunic, or had
 not reached the mucous  membrane, we might, as Desault recom-
 mends, effect the reduction of the  parts  and await the result from the
 resources of the organism.   But  of two things  one must happen:
 either the gangrene is evident, and in this case the surgeon not hav-
 ing the means of ascertaining with  certainty whether it will extend
or not throughout the whole thickness of the intestinal parietes, can-
not venture upon attempting  reduction; or its existence is question-
 able, and in that case prudence suggests that the intestine should be
 returned into the belly.  If the gangrene occupies only a small space
 we must remove the  portion of the intestine which is the seat of it,
 by incising upon the living part in such manner as to make an ellipti-
 cal wound lengthwise or  transversely, according as the same  shall
 present a greater or less facility of being brought into harmony either
 with one or the other of these two directions.  On the contrary, should 
294
NEW ELEMEXTS OF OPERATIVE  SURGERY.
it extend over  a large portion of the  periphery of the intestine, it
would  be  better to remove an entire  segment  of this cylinder, in
order to make trial of one of the operative processes mentioned
above.   When  the gangrenous portions  have been  once removed,
the solution of continuity is reduced  to  the  condition  of a simple
wound and is to be treated like that.
  E. Wounds of the intestines.—Modern labors  have demonstrated
that the perforation of an intestine by a  pointed or  cutting instru-
ment, may be left without danger  in the abdomen, provided it  has
less than two or three lines of diameter.  The muscular fibres soon
pucker up its edges, in such manner as to compel the mucous mem-
brane to become entangled in it, so as  to close it up.   Nor does an
incision of somewhat greater extent, as one of three or four lines for
example, always give rise to an effusion; its borders  sometimes  be-
come agglutinated to the corresponding surface of another intestinal
convolution, or it  may come in contact with  a fold  of the epiploon,
which frequently becomes lodged in it, and closes it  up in the man-
ner of  a plug.   I have in two  instances  reduced an intestine, per-
forated in  this manner, without any unpleasant consequences result-
ing. M. Vidal  has communicated to me a similar fact, and these re-
sults are calculated to diminish to a great degree the importance of
sutures, and of  the operative processes above mentioned. I shall re-
cur to them again  in treating of artificial anus.  It would, neverthe-
less, be imprudent, when such  lesions are exposed to  view, to aban-
don them to the efforts of nature.  Though it be true that the  great
majority of  them will succeed  in healing up  without producing any
accidents,  it is also very probable that others might be attended with
a fatal  effusion.
  I. In hernias, these wounds present themselves under two distinct
forms ;  1st, in the condition of a simple division, when  they have been
made by the cutting instruments used  by the operator; 2nd, under
the aspect of an ulcer, or solution with a loss of substance, where the
constriction of the ring has been  the  cause.  In this  last case we
can scarcely hope that  they will  close up without  assistance, and
should we decide upon treating them by the  suture, it would be ad-
visable  that their  borders should  be  previously regularized.  We
have here the choice of the glover's, the noose, and  the interrupted
suture.  The glover's suture has the advantage of being prompt and
easy, and  of closing up the wound accurately ; only that it is  difficult
to withdraw the thread when we suppose the  reunion to have been
accomplished.  The noose suture, or that of Le  Dran, besides being
less prompt, possesses the disadvantage of puckering up and contract-
ing the intestine, in consequence of the breadth  of the wound ;  but
the threads  having been passed only once through  the tissues  are
easily removed and withdrawn through the opening  in  the abdomi-
nal walls.   This suture,  slightly modified by M. Jobert, (Bull, de
VAcad. Roy. de Med., t. I., p. 332,) who had* opened into the intes-
tine, while operating  for a crural hernia, succeeded perfectly;  but
death was the  result of  it in two other cases which were published
by M. Fleury,  (Arch. Gen. de  Med., 3e ser.,  t. I., p.  297.)   The in-
terrupted suture possesses nearly the same advantages as the glover's,
 and if it should be modified as was proposed  by Beclard, there will 
HERNIOTOMY OR KELOTOMY.
295
 be less risk when removing  it, of lacerating the adhesions and the
 forming cicatrix, than there would  be with  the  simple whip suture.
 It is nevertheless the spiroidal suture, combined with the principles
 of M. Lembert, which would appear to deserve the preference over
 all.  Whether the wound be longitudinal or transverse, the operation,
 notwithstanding, is to be performed after the same rules.   When the
 adossement is completed, we may proceed in two different manners.
 First, by knotting the suture and dividing  it  close to the intestine,
 then reducing this last, and leaving the suture free in the cavity of the
 abdomen; or second, we may retain the thread on the contrary, and
 attach it to the dressing outside, in order to  prevent the wounded or-
 gan from escaping to any distance, and to compel it to attract adhe-
 sions behind the  ring. If it were certain, as is averred, that ligatures
 inserted into the  tissues of the intestinal coats, would always fall into
 the interior of the canal, the first method ought evidently to be  pre-
 ferred, since the other must necessarily present more or less obstruc-
 tion to  the progress of the matters; but the majority  of surgeons
 have not yet adopted this  mode of proceeding.   The two cases of
 M. Cloquet and M. Liegard, both of" whom followed  the process of
 M. Lembert, are in fact  the only instances,  which up to the present
 time can be cited in its favor.
   II.  AI. Raybard even  considers, under such circumstances,  that
 the principal intention of enteroraphy is to attach the two lips of the
 wound separately, behind  the opening, into  the walls of  the belly, in
 order that when they have once become agglutinated to the perito-
 neum, we may withdraw their threads, and cure with one operation
 the wound  of the belly  and that of the intestine.   If the wound is
 longitudinal  this  practitioner proceeds in the following  manner:  a
 small thin oiled piece of  light wood twelve  to fifteen lines in length,
 and  four to six in breadth,  is first introduced into the interior of the
 intestine.  A noose of thread attached upon the middle of this piece
 of wood, and the two extremities of which thread are  each armed
 with a needle, is  then  passed from one side to  the other, and from
 the interior to the exterior, and  through the entire thickness of the
 walls of the abdomen, in such manner that  the small plate of wood
 presses at the same time  the two lips of the intestine against the  two
 sides of the abdominal wound, which latter  it also at the same time
 keeps  hermetically closed.   When the adhesion of these different
 tissues appears to have  been sufficiently consolidated M. Raybard
 withdraws his thread; the little plate of wood comes away with the
stools, and from  that time we have nothing more to attend to than
the cicatrization of the wound of the belly, if, in fact, that has  not
already been accomplished.  If  we may object  to this process, that
it produces designedly adhesions which necessarify prevent the in-
testine from reacquiring  its primitive mobility, it is proper to  add
that  in the other  sutures  the same thing is almost as certain to take
place, if not to as great  an extent, also whenever we retain the ex-
tremities of the thread at the outside.   It  may be also said with
truth, that when we abandon the intestine behind the wound, after
having divided the thread close to the peritoneum, we do not even
then any more escape this result.  The adhesive inflammation essen-
tial to cicatrization scarcely ever fails to unite the periphery of  the 
296          NEW ELEMENTS OF OPERATIVE SURGERY.
 visceral wound  to  the tissues which  cover and surround, or are in
 immediate contact  with it.  Another  objection is that  the employ-
 ment of the plate of wood, though applicable to longitudinal divisions,
 from penetrating wounds into the abdomen, are no longer so in cases
 where  the parts have escaped through a  hernial opening.  There
 would also, moreover, be danger  that the extremities and  edges of
 this foreign body  might  perforate by ulceration or gangrene  the
 coats of the wounded intestine.
   III.  In  conclusion, therefore,  whether  we  retain the intestinal
 noose or leave it in  the abdomen, it cannot cicatrize  without becom-
 ing  adherent to some extent  with the neighboring parts; so that
 under this point  of view, everybody should be left  to act according to
 his own particular  ideas.   Nor can I  seriously  blame M. Guillaume
 for using the suture to the exterior wound, in a patient  in whom he had
 employed, for a division of the intestine, the glover's suture.  Finally,
 if the walls of the organic cylinder should  not have  been divided or
 perforated  but  to the extent of  one  or  two lines, we should have
 acted still more promptly by seizing its two lips  at once with the for-
 ceps, and closing them by passing a ligature around them, in the same
 way as in tying the extremity  of an artery.  M.  A. Cooper and
 another surgeon, I believe, have each succeeded in a  case in the hos-
 pitals of London by acting in this manner.

              § IX.—Accidental or Artificial Anus.

  The operations, by means of which art has sometimes succeeded
in the cure of artificial anus, are  quite few.   For a  long time even
no attempt was  made to devise  any,  and it  was scarcely until the
 middle of the last century that operative surgery  seriously occupied
itself with  this disgusting infirmity, which, in the case of a woman
mentioned  by Wedemeyer, (Journ. des Prog., t.  IV., p. 234—Bull.
de Fer., 1. XII., p. 64,) was  cured by her becoming pregnant,  and
which  I have myself seen  in two instances, and as has been related
in many others, frequently disappears also of itself.
  A. Suture.—One of the earliest processes whteh  here suggested
itself to the mind under the character of an operation,  was the suture.
 It would naturally  appear that  by approximating  the lips of the
wound previously abraded, and by maintaining them  in  contact, we
 should compel the matters to resume their natural course, and to pass
into the lower end of the  intestine.  Lecat, who was  the first to de-
 clare his intention of putting this method into execution, had admitted
mto his hospital,  in the year 1739, with the object  above  indicated, a
 woman who had heen affected with artificial anus for several months ;
 but various circumstances, over which he  had  no control, led to a
 failure of his essay.  Lebrun was more fortunate, and  carried out into
 practical operation the idea of Lecat.  A suture in the  form of a cross
 appeared to him to  answer the purpose in the patient who fell under
 his treatment.  For  the purpose of abrading the  lips of the wound, he
 made use of a caustic. For two days every thing appeared to promise
 a successful issue ; there were no accidents, and  the cicatrization had
 already advanced very far, when on the third day it became necessary
 to remove the threads and to give issue to the matters.   Lebrun wait- 
HERNIOTOMY OR KELOTOMY.
297
 ed with the intention of renewing the operation at a somewhat later
 period, but the patient would not listen to any such proposal.  This
 attempt, which few surgeons have ventured to repeat, has been gen-
 erally condemned.   It however has been made trial of by M. Judey.
 (Arch. Gen.  de Med., t. I., p. 291,) for an accidental anus which had
 existed for four months.   The success was complete, according to M.
 Richerand.  M. Blandin appears to  have been  less fortunate, as ac-
 cidents soon obliged him to  reopen the wound.
   B. Anaplasty.—It was natural that a modification of this process
 should be  suggested, and  such  in fact has  been the  case.   The in-
 teguments in general are so  indurated and so blended with  the sub-
 jacent tissues at the periphery  of the wound, that  it  would  be diffi-
 cult to approximate its lips or to bring them into contact.   M. Col-
 lier has suggested that a portion of skin detached from the neighbor-
 hood,  and  brought forward  and attached by threads or pins on  the
 accidental anus, according to the principles  of anaplasty, would ob-
 viate this  inconvenience.  A patient treated by him in  this  manner
 was perfectly restored, and  it is a  mode of proceeding which I shall
 recur  to again farther on.
   C.  Compression.—Compression is a method which has been made
 use of with advantage in more than one instance, and is still frequent-
 ly employed at the present  day.   It  is moreover  in  many cases in-
 dispensable as a  preparatory or subsequent  auxiliary means, to re-
 move  certain complications which would render the application of
 the other processes altogether impossible.
   I. Strangulation of the invaginated intestine.—The intestine may
 become invaginated through the artificial  anus, protrude to the out-
 side, and ultimately, in certain cases, form a tumor which has been
 seen to acquire the size of six inches, and even a foot  and more  in
 length, assuming  the  form of a cylinder, through the extremity of
 which  the alimentary matters made their escape.   It is  evident that
 an  invagination  of this kind constitutes  of itself a serious  disease.
 Thus,  as Hebreard  (Bull,  de  la  Fac de Med. de  Paris, t. I., 2d
 year)  saw  in a  patient who had  been affected in this  manner for
 twenty-four years, and as  many other surgeons have also had an op-
 portunity of remarking, its root is liable to become strangulated like
 any other  species of hernia.   Patients have died in  consequence
 thereof.  I have no need of  remarking, that when this strangulation
 exists,  we  ought,  if the reduction  cannot be effected in any  other
 manner, to lay bare the ring and incise it from within outwards, in a
 word, divide the stricture as  in ordinary hernia.  The case of a child
 mentioned by Hippocrates, the young man cited by F. de Hilden, and
the cases of Albinus, Lecat, Puy, Leblanc, Schmucker, Bidault, Saba-
tier, Desault, Scarpa, and Howship, collected by M. Arronshon, (Mem,
de Chir., 1836, p. 26,) who also saw one himself, show what  the sur-
geon has grounds for apprehending from these eversions  of the intes-
tine through an accidental  opening  of the walls of the abdomen.  The
 debridement  performed by M.  Veiel, (Arch. Gen. de Med.,  2d ser.,
 t. VII., p. 542,) in a case of this kind, did not prevent a fatal issue.
  II. Compression of the invaginated intestine.—Even in the absence
of any constriction, the intestinal cylinder, with its mucous membrane
thus everted and outside of the ring, does not remain long in this  position
  vol.  m.                      38 
298
NEW ELEMENTS OF OPERATIVE SURGERY.
without undergoing various alterations.  Thus there is danger that
the peritoneum of its invaginated portion may soon contract close ad-
hesions with that of the containing portion, and that the other tunics
may become thickened and indurated to such degree as to render its
replacement difficult or even altogether impossible. It is for the purpose
of remedying accidents of this character that compression has been
recommended.   Desault, Sabatier and Noel, were the first to point
out its efficacy, since which it has become a resource which to some
extent is in common use.  If the tumor is long, it is to be enveloped
with  fine  compresses after having cleansed it,  and we then apply
over  it a  bandage in the same way as in adjusting a roller bandage
on the limbs.   During the first days, the diminution of a mass of this
description being very rapid, the  bandage should be  renewed fre-
quently. At a later period it is only to be reapplied at longer intervals.
If the serous surfaces of the organ do not present an insuperable ob-
stacle to this course, we shall soon  have it in our  power to return the
intestine into the belly.
  III.  Compression of the spur, (Veperon.)—It is evident, moreover,
that after  this reduction the artificial anus will nevertheless continue
to remain,  and that something else is required to effect the removal of
this.  As the projection, or species of spur, or prominent border which
separates the upper from the lower end of the intestine, is the principal
obstacle to the passage of the matters from the first into  the second, it
was natural to hope that  by pushing back this projection we should,
in some instances, succeed in effecting a cure.   Compression, there-
fore, was  suggested for this also.   It is in the school of Desault that
it has received the greatest number of partisans and useful improve-
ments.  Desault expected by means of tents, first introduced into the
lower  and then  into the upper end, and fastened at the outside by a
thread which embraced the middle portion, to clear out in this  man-
ner for the matters a passage which they  would soon  take.  After
having inserted his meche, he applied a pyramidal tampon on the epe-
ron to support its convexity and to push  it as far as possible towards
the belly.   By this means he gradually depressed the  eperon, and
finally succeeded in  obliterating a great portion of it.   After these
meches could  be introduced of a  large  size, and that the stools had
become almost perfectly free, he confined himself to compressing the
exterior division in order to prevent by  this means any kind of exu-
dation.  It cannot be denied that a treatment  so judiciously  con-
ceived has in more  than one  instance been followed by success.
Nevertheless the presence of a tent filling up  the two ends of the
intestine, and of the pyramid of lint or of compresses which hermeti-
cally close the wound, is not always supported by the patient without
some inconvenience.  Some under such circumstances are attacked
with  colics and pains so acute  that the method  has to be laid aside.
Another means of effecting the same result has been sometimes em-
ployed at  the Hotel Dieu.  This is a species of  crescent of ebony or
ivory, six  to eight lines in length, having a handle five  or six inches
long, and fitted with a sponge or compress.  This being introduced to
the bottom of the accidental anus, embraces by  its concavity the in-
testinal projection, which  is pushed back  by  making pressure upon its
handle, which is  likewise wrapped in  linen, and which may be 
HERNIOTOMY OR KELOTOMY.
299
easily kept  immovable by means of a truss  or any other suitable
bandage.
  D.  Enterotomy.—The labors of Scarpa in elucidating the mechan-
ism of this affection, have shown that what this author calls a.promon-
tory is caused  by the  adossement of the two  ends of the intestine,
which present themselves behind the ring in the manner of the bores
of a double barrelled gun. Such being the fact, they naturally sought
means not only to push back this eperon, but in fact to destroy it.
  I. Schmakhalden appears to have been the first to have conceived
this idea, which he made public in his inaugural dissertation in the year
1798. He recommends that we should traverse, by means of a curved
needle,  the  base of  the eperon, and that we  should thus introduce
through it a strong ligature, in order, by making traction upon this
thread,  to cut  through it by degrees  in a  longitudinal direction, or
that we should proceed after the manner of treating fistula in ano by
apolinosis.
  II.  According to J. S. Dorsey, (Elem. of Surg., vol. II., p.  96,)
Physick made trial  of a similar  process in January, 1809, and suc-
ceeded perfectly.
  III. The proposition of the German surgeon received no attention
in his own country, and that of the American author would also pro-
bably have passed unnoticed, had it not been that Dupuytren, about
the same epoch, viz., in 1813, made an effort on his part to bring it
into repute in France.  Like Physick, the surgeon of the Hotel Dieu
limited  himself, in his  first trials,  to the  introduction  of a thread
through the  eperon, in  order to cut through it from behind forwards.
The adhesions which the peritoneal surfaces would  contract around
the  adossement, were calculated to prevent any kind of effusion into
the  belly.   The matters being no  longer pushed towards the ring,
and finding an outlet in the lower end  of the gut, would naturally
take that route and resume their course towards the rectum. Though
several trials had confirmed these anticipations, Dupuytren soon per-
ceived, however, that  the needle  might go beyond the protecting
adhesions, and perforate a point of the  alimentary tube, communica-
ting with  the interior of the  peritoneal cavity.   Intimidated by this
danger,  he devised an  enterotome, the inner face of whose branches
was undulated, in order that it  might  more accurately embrace the
parts, and that these latter might not slip upon  each other.  Being ar-
ticulated in the manner of a forceps, its extremities in the direction
of the intestines, were  shut and approximated  by means of a screw
passed through its handles.   One  of the branches of this instrument
was to be applied upon each portion of the intestine, in such manner
as to  include its  eperon to the extent  of an inch or an inch and a
half.  The pressure necessarily brought about the  mortification qf
the  tissues, and an immediate  interruption  to the circulation.  It is
easy to understand  the character  of a process of this description.
The peritoneum is placed in contact with itself upon the periphery
of the enterotome. The eliminative inflammation developes itself by
degrees, and is transmitted  to the distance of some lines upon the
outside.  Solid adhesions are the necessary consequence, and no per-
foration therefore is to  be apprehended in  the  direction of the peri-
toneum.   In proportion as the eschar detaches itself, the instrument 
300
NEW ELEMENTS  OF OPERATIVE SURGERY.
 becomes more and more movable, and comes away entirely, as soon
 as  the former is  completely isolated.   Should the compression not
 have been sufficiently powerful at first, the blood might still continue
 to circulate between the branches of the forceps.  In that case the
 gangrene would not take place, and the exterior peritoneum  might
 not be inflamed to a sufficient extent to bring about the adhesions
 required.  We would have to apprehend a  perforation  in the direc-
 tion of the belly, and the failure of the  division of the  morbid sep-
 tum.  And even admitting that it should have  taken place, the pain
 notwithstanding will be  more acute, and the cure much  more  tardy.
 This method, which was.employed in more than twenty instances by
 Dupuytren, and afterwards by MM. Hery de Bonneval, Lallemand,
 Delpech, Simonin,  (Decade  Chir., 1838,  p.  75,) and  other  practi-
 tioners, has up to the present time occasioned serious accidents only
 in a small number of cases.  As soon as the perforation is effected, the
 matters pass into the lower intestine and the stools are re-established.
 Each day less and less passes through the wound, which latter speed-
 ily contracts, and is soon reduced to the character of a simple fistula,
 if it is before the cicatrization has been entirely accomplished.   Fever
 rarely follows, and some symptoms of  colic or of inflammation, ex-
 tending to a slight distance towards the intestine and peritoneum, are
 the only accidents that have been  noticed, while in most cases the
 patients rarely experience any inconvenience from its  employment.
A patient, however, operated upon by M.  Lesauvage, (Arch.  Gen.
de Med.,  2e ser., t. XII., p. 351,)  died after the expiration of  a few
months, though there was a  decided contraction of the perforation.
I have seen a woman die on the tenth day from this process, in con-
sequence of peritonitis.  The eschar, which  had detached itself  on
the sixth  day, had not yet become surrounded with adhesions, and I
know that similar results have been noticed in other hospitals.
  IV. Some  persons, however, have endeavored to make an addi-
 tional improvement  of  this  process by modifying the enterotome
 forceps.  Thus, M.  Liotard  has suggested an instrument or species
 of punch, which is made use of by M. Blandin,  and which cuts out a
circular flap from the morbid septum without touching its free bor-
der, in such  manner that an opening is  thereby made, which is
 modelled in some respects  after that  of a natural intestine.  This
 process would possess the disadvantage  of not  being adapted to  all
 cases, that of incurring the  risk  of pinching up some sound portions
of a free noose of the intestine, which  might happen to get behind
or between the two branches of  that  portion of which we were de-
sirous of perforating the septum  of adossement, and finally, the dis-
 advantage of being difficult of execution, for the plates of M.  Liotard
 are too large to  be easily introduced  through any artificial anus
whatever, or  through the ends of the  intestines themselves, which
 latter, in  such cases, are usually contracted  to a very considerable
 degree.
  V. Delpech has used an instrument which acts nearly  on the same
principle  as that of M. Liotard.   This enterotome, revived as  some-
thing new, and used in one instance with success by M. Lotz, (Gaz.
Med., 1836, p. 746,)  is  a long forceps,  terminated by two concave
hemispheres (coques,) slightly elongated, and very nearly similar  to 
HERNIOTOMY OR KELOTOMY.                301
die shells of a walnut, and  the circumference  of which is "slightly
concave  in the direction  of their  length.  They are introduced
separately;  as they do not make compression at first, except at their
beak, the septum is divided only by degrees, and from behind for-
wards, while with  the enterotome  of Dupuytren, the compression
being generally so much  the greater in  proportion as we approach
nearer to the heel of the instrument, the gangrenous  division is ac-
complished from before backwards.  Delpech, moreover, was fully
conscious that his  forceps, though useful perhaps in some particular
cases, could not in general be substituted for that of Dupuytren or
that of M. Raybard.  It might, I should imagine, possess some ad-
vantages when the septum is exceedingly long and situated at a great
depth, or when, in order to reach it, we are obliged to pass through
an irregular and more or less sinuous passage ;  but these are  details
which can never be subjected to the rules of a systematic description,
and which  must be left to the judgment of the surgeons to  whose
notice the cases present themselves.
  E.  In this method, moreover, as in every other two things are to
be distinguished, the object in view, and the means by which  it is to
be attained.  It is upon these last only, as it appears to me, that there
can be any difference of opinion at  the  present day, and there is no
reason why we should not make still further attemps to simplify them.
Since by depressing the eperon in artificial anus, we make  a passage
for the matters, why not effect this depression by means of a canula,
which would at the same time allow of the cicatrization of the ex-
terior division ? This advice has been given by M. Colombe, (Bibliot.
Med., 1827, t.  I., p. 389,) and M. Forget  informs me that he advan-
ced a similar opinion  in the year 1824.  M. Colombe recommends
that we should insert  the extremities  of a  large gum-elastic  canula
two to three inches long, into the two ends of the intestine, which
canula being slightly curved, would rest at its concavity upon the
free border of the septum, and would have attached to the middle of
its  convex side a thread, for the purpose of retaining it until the
wound should  have almost entirely closed up, or that  the course of
the matters had  been sufficiently well re-established to lead  to  no
farther apprehension  of  their escape externally.   At first sight a
process of this kind seems to be worthy of consideration, and ap-
pears to  be specially applicable to those cases in which the enter-
ing (rentrant) angle formed  by the mesenteric wall of the intestinal
noose is very open, and where the eperon is  not  very projecting,
and to those cases more particularly, in which the intestine has not
been destroyed throughout the whole extent of its circumference;
but in the  others it is to be apprehended that it would prove  insuffi-
cient, and  that it would have to  give place at least to the process
of Dupuytren.  I would  remark, that in order to have a decided
prospect of success, it would be necessary  to  make  use of a large
sized canula, the introduction of which should necessarily be attend-
ed at first with a considerable degree of difficulty.   I used it at  La
Pitie, in the month of August, 1831, and the patient succumbed three
days after, under symptoms of an intense peritonitis.   The intestne
was perforated behind, and the canula had  perforated into the open-
ing.  Whether this perforation  was the effect of  ihe  canula or a 
302
NEW ELEMENTS OF OPERATIVE  SURGERY.
 simple  coincidence, certain it is that a result of this character does
 not speak much in favor of the method.
   F. Excision.—It is proper to remark also that  the process of Du-
 puvtren is not the onlv one which might  be attended with  success.
 Ml Raye (Bull. Med. de Gand.; Gaz. Med., 1838, p. 445) seizing the
 eperon  with a good pair of polypus forceps, afterwards  excised a V
 flap from it with the scissors, and his patient was  promptly cured.
   G. Complications  to be  encountered.—When the  surgeon  has
 decided upon undertaking the cure of artificial anus he  must reflect
 at first upon the difficulties which in certain cases present themselves,
 to the introduction of the enterotome.   If  the integuments have not
 been largely laid open, or if from any cause whatever there should
 have been developed  in  the neighborhood  sinuous passages or ster-
 coral fistulas, or if a tumor or openings or an erysipelatous inflamma-
 tion exist in front of the gut which it  is our intention to enter, there
 can be no doubt that we ought to begin by combatting and getting
 rid of these  various  impediments, either  by  means of the proper
 incisions or excisions, or by sanguineous evacuations, general and
 local, topical emollients  or  laxatives, baths, lotions, &c.  It was in
 this manner I saw formed in a patient whose strangulated hemia had
 never been operated upon, five or six openings and a tumor  as large
 as the fist in front of the ring, a tumor which was occasioned by
 the thickening  and habitual chronic inflamed state of the  skin, the
 cellular  and  adipose  tissue  and various lamellae contained in  the
 inguinal canal.   I was thus obliged to circumscribe this mass by two
 semilunar incisions, and in  order to  remove it  was compelled  to
 cut down to the root of the spermatic cord,  that I might lay bare
 the intestinal opening.   In  such  cases  moreover it is to be recol-
 lected that the operation is  to be performed in two stages ; that is,
 before proceeding to the use of the enterotome we must  wait for the
 cure  of the wound  which has been made.  In other  cases  we are
 obliged  to dilate for a  week or two the artificial anus itself.   In cer-
 tain others the cutaneous orifice is so remote from the intestine that
 we meet with  considerable difficulty in penetrating into this last.
 The perforated noose of intestine may also be  tortuous or twisted,
 either in the interior of the canal  itself or  behind  the ring, or it may
 have  formed duplicatures which have contracted adhesions with
 each other, and  thus give rise to difficulties which it is important to
 overcome before proceeding farther.    The lower end  also of the
 intestine, which is always contracted to a great degree, may be situ-
 ated  above the upper  end, around which it  may have  become
 twisted  in the manner mentioned  in the case which is found in the
 memoir of Delpech.  Though the obliteration of this portion of the
 alimentary tube, however ancient the disease may be, is  unfrequent,
 it  is however possible.   A case noticed at the Val-de-Grace in an
 old man who had  had  an inguinal artificial anus for forty years,
 places this fact beyond dispute; so that it is as well to think of this
 fact  before applying the forceps upon the  septum we are about to
 destroy.   At however slight a' depth therefore the wound  may be
 situated, or however little doubt may exist  upon  the character of the
relations between  the orifices of the  abnormal anus, we ought to
endeavor to dilate gradually the  passage  which  conducts into the 
                   HERNIOTOMY  AND KELOTOMY.               303

upper intestine, and do the same for the lower also, by means of long
meches, bougies, sounds and  gum-elastic canulas, or by portions of
prepared sponge, and never have recourse to the enterotome before
having been enabled, by means  of the finger, to recognize the posi-
tion of the parts and the relative situation of the septum with both
ends of the intestinal tube.
  H. The Operative Process for  Enterotomy.—When we  have
reached this point  the  operation, properly  so  called,  may be per-
formed.  The patient is to be placed in the  same  manner as for
kelotomy.  The forefinger of the left hand serves as a  guide to one
of the branches of the  forceps, which it conducts under the lower
surface of the eperon to be destroyed.   An assistant is directed to
keep it in  its place, while the operator introduces the  other in the
same manner into  the  upper end of the diseased tube.  He now
grasps both the branches;  turns them upon their axis  in such man-
ner as to be enabled to unite them together;  passes his finger almost
as far as their extremity, in order to  ascertain to what extent they
embrace the eperon and to what distance he may insert them with-
out danger up to the point where he wishes to effect the mortification.
The quick  screw or any other suitable means  for  shutting  them, is
immediately  applied upon  the extremity  of their handle, and  com-
pression made to the degree required for suspending, as we  have
said, the  circulation or  vitality in the septum which they embrace.
Nothing  more remains  to  be done than to surround them with lint
and compresses, and secure the whole  by  means of a bandage, which
terminates  the operation.  The patient  being  carried back  to his
bed, is subjected to the regimen used in serious  operations.   The lint
and  other  portions  of the dressing  are  to be  renewed as often as
the exudation of the matters  require,  taking care  however that the
requisite precautions are observed to prevent the forceps from being
disturbed in their position.  Should  accidents be developed they are
to be met by such means as each one of them may require; as soon
as any gurgling sounds  are heard or the least tenesmus manifests
itself, irritating injections become  absolutely  necessary, especially
when the instrument begins  to  be  loosened, and when the  separa-
tion of the eschar  should appear to have already taken place.  The
subsequent treatment has nothing further of a particular character;
the patient should maintain  the horizontal position, take  from  time to
time an aperient, have recourse  frequently to enemata, and take all
kinds of nourishment.
  I. In respect to those kinds of artificial anus whose cure cannot
or ought not to be attempted,  the best  means to be employed is the
species of box contrived by  Juville.  Any other description of vessel
constructed on the same principles,  and those kinds of vessels or in-
struments  which are found at most bandage-makers or manufactu-
rers of surgical instruments, would moreover fulfil the same intention.
  J. Additional remarks upon artificial anus.—It would be readily
supposed,  from what has preceded, that  artificial anus is a disease
which can require no farther investigation.  One important step was
to have established in a precise manner the influence of the infundibu-
liform contraction of the  peritoneum upon the  progress of the matters
towards the neighborhood of the fistula.   Another was that of show- 
304
NEW ELEMENTS OP OPERATIVE  SURGERY
 ing that if the contents of the alimentary tube escape by the acci-
 dental opening, rather than continue to pass from the upper into the
 lower end of the  intestine,  it was to be imputed to the septum or
 species of promontory or mesenteric eperon situated  between them.
 A third point gained finally, and  unquestionably the most important
 of  all, was the knowledge how to destroy this eperon, since the cure
 of  the disease  depended upon  that result.   The  knowledge in fact
 that we could obtain this result has, in some measure, thrown the
 other acquisitions, made  into oblivion.   The  minds of surgeons, ex-
 hausted as it were by such  successful results,  have  from  that time
 fallen  back  again almost into  a  state of perfect indifference.   In
 this respect however, as in  many others, surgery is  still  far  from
 having reached perfection.   The adhesion of the intestine to the
 root of the sac is frequently  less intimate than Scarpa alleges.  The
 membranous funnel is frequently wanting.  The adhesive inflam-
 mation does  not always take place at the periphery of the entero-
 tome, even after it has been  applied in the most judicious manner.
 In  some cases it  is almost  impossible  not  to  include between the
 branches  of the instrument a portion of some  important  organ at
 the same  time with the abnormal septum.   Finally, many cases of
 artificial anus and  of stercoral fistulas will persist to an indefinite
 period of time, in  spite of the  destruction or absence of every kind
 of eperon.
  Georget, a farmer, 39 years of age,  entered  into my department
 of the hospital of La Pitie, on the 28th October, 1834.  I examined
 him at my visit on the 29th and perceived  at the outer angle of the
 right  pubis,  a red  colored border formed by the everted intestine.
 Below this was found a fistula which allowed of the introduction of
 a probe into  the  perforated intestine.   The  patient was  anxious
 and desired  to  be  operated upon  immediately.   On the 2d Novem-
 ber an acute erysipelas made its appearance around  the wound and
 death took place on the 9th.
  Morbid Appearances.—1.  The upper portion of the ileum is attach-
 ed to the inner  and lower portion of the inguinal ring, where it is
 slightly adherent, and in such manner as to be continuous with the
 fistulous ulcerations noticed  during life.  2. The lower end of the
 same intestine ascending  from the pelvic cavity into the iliac fossa
 turns round  upon the outside of the other, in  order to enter into the
 hernial canal, and to reach down to the  groin, where it formed the
 actual orifice of the artificial  anus.  3. By raising  these two portions
 posteriorly, they were so easily separated from  the neck of the sac
that the slightest effort would have been sufficient to produce an effu-
 sion into the peritoneal cavity.  4. It would  have been impossible
during life, to have strangulated the  eperon by means of the entero-
 tome, without causing this effusion.  5. There was not the slightest
appearance  of infundibulum,  and the sac was  closely adherent to
the  inguinal  canal.   6.  The two portions of the intestine were in con-
tact at their  side, and not at their  mesenteric  border.   7. At differ-
ent  intervals this adossement was merely that of  contiguity, and in
such manner as to  allow it to be destroyed without the slightest rup-
ture.  In this case, therefore, the total  absence  of infundibulum or
of a membranous  funnel, would have constituted  an insuperable ob- 
HERNIOTOMY OR KELOTOMY.
305
 stable to the spontaneous cure of the artificial anus, which  however
 had existed for the space of seven months ; while the feeble character
 and extent of the adhesions would have almost unavoidably occasion-
 ed a fatal  effusion into the belly, had the slightest operation  been at-
 tempted.  IJpon the supposition that we could have succeeded in de-
 stroying the intestinal septum, the  matters nevertheless would have
 doubtless  continued to pass through the  wound, since even in  that
 case the contortion of the intestine would have rendered  their trans-
 mission from the upper into the lower gut next to impossible.
   The following is a fact of another character, though not dissimilar
 to the preceding.   Martigny,  a day laborer, 56 years of age, had been
»laboring under a crural hernia on the  left side,  for the space of 18
 years.   On the 17th April, 1835, there came on vomitings, and a few
 days afterwards symptoms of inflammation.  The patient entered La
 Charite on the 26th of the same month.   The fold of the left groin
 presented a  red irregular tumor, which exceeded the size of an  egg.
 Repeated  efforts of the taxis  were unavailing.  Gases of a gangre-
 nous odor were disengaged, and the mortified  parts were  excised.
 Two incisions were now made at the seat of the strangulation.   On
 the 30th April the dressings were saturated with faecal matters, but on
 the 6th May the pain had almost subsided.  On  the  10th, compres-
 sion was applied by  means of small balls of lint, and on the  14th the
 forceps of Dupuytren were introduced and tightened upon the eperon.
 On  the  18th, the patient experienced only some slight attacks of colics
 at intervals,  when the forceps were gently tightened  again.    On the
 19th the colics were more violent,  with pain on pressure in the hypo-
 gastric  region.   Nauseas with vomiting succeeded, and  on the  20th
 the  symptoms  became more  aggravated, and the  belly exceedingly
 sensitive.  On the 21st,  we removed the forceps, which were found
 to include between its branches a portion of gangrened  intestine.
 The belly  was tympanitic, and the  face shrunk, and death took place
 on the afternoon of the 22d.  A part of the epiploon  was found ad-
 herent in front of the strangulated intestine, and shutting up its cavity
 on the left.  On turning back this  epiploon, we found the two  ends
 of the intestine with their  lips detached.  Upon  the inside,  the  epe-
 ron was destroyed to the extent of two inches ; but there was no ad-
 hesion except on one of the sides of the division.  The other  border
 was cut perfectly smooth, and it was evident that  a  certain portion
 of the stercoral liquids had made their escape through here.  The pus
 in the neighborhood was tinged with them, and the entire peritoneal
 cavity was filled with sero-purulent matters.  The entero-mesenteric
 septum had prolonged itself into the groin.  The  remains of the sac
 exhibited no disposition to become  displaced, or to be drawn in the
 direction of the belly.  There are  no  reasons  for  supposing  that it
 would have been possible to have established in that place a  membra-
 nous funnel.   In this case, the adhesion which the enterotome usually
 causes around  the portion of tissues it strangulates, had been  but im-
 perfectly accomplished; it is  also to be added that in front, where
 alone this  adhesion existed, it would have been  impossible  for it to
 have retained the matters without the expansion of the epiploon which
 covered it.  Moreover, inasmuch as from the first  to the fourth  day,
 no accident  supervened, we may affirm I think, that the peritonitis
   vol. in.                     39 
 806          NEW ELEMENTS OF OPERATIVE SURGERY.

 was the result of the mortification of the eperon, and not  of the her-
 nial strangulation.
   A woman whom I  operated upon in 1833, with Dr. Bonis, for an
 enormous strangulated gangrenous umbilical hernia, died two months
 afterwards with an artificial  anus, in my department at the hospital
 of La Pitie.  The particulars in relation to the operation were com-
 municated at  the time to the Roval Academy of Medicine, (Arch.
 Gin. de Med., 2e ser., t. II., p. 285.)  I wish to recur at the present
 time  only to  the  portion which relates to the condition of the parts
 in the belly.   It was  the small intestine which had  escaped through
 the umbilicus, and the convex border of its upper end  was the only
 portion which remained partially  adherent behind the ring.   The •
 other end was  more  than an inch  distant  from it; nevertheless no
 effusion had  taken place into the abdomen.  The epiploon on  one
 side, a sound noose of the intestine on the other hand, and thirdly, a
 false  membrane, had  become  agglutinated all around, as if for the
 purpose of forming the canal  or funnel down to the  umbilicus.   The
 matters thus, which had never absolutely ceased to pass into the cae-
 cum, must, before issuing from the wound or entering into the lower
end of the perforated  intestine, have fallen or glided down upon  this
species of accidental plane.  The sinus, or cul de sac, corresponding to
 the mesenteric side, was occupied moreover by another portion of the
small intestine, bent into an acute angle, and agglutinated  in a solid
 manner upon the points upon which the enterotome would have had
 to have been applied, had it been judged advisable to undertake  the
operation.  We perceive, therefore, that it not only would have been
 difficult to have reached the eperon, but moreover that in compress-
 ing this septum, we should have inevitably strangulated another noose
of the alimentary canal, and caused the death of the patient.
  K. An anus without eperon.—Artificial anus and intestinal fistu-
 las unaccompanied with an eperon, may be established in three  ways
 that are quite different: 1st.  If after the reduction of a hemia which
 has been previously operated on or not, an opening shall have formed
 upon the convexity of the intestinal noose, it'may happen that  the
 matters issue in the direction  towards the skin, and  that an artificial
 anus will be the consequence.   2d. An ulcer commencing in the mu-
 cous membrane may cause an adhesion of the intestine to the corres-
 ponding part of the abdomen.  Continuing its progress outwardly, and
 having perforated all  the tunics, this ulcer will cause a  stercoral
 abscess and may terminate in  a fistula.  As the intestine is not dis-
 placed, it may neither be bent into ah angle nor contracted.  Hence
 in such cases the  artificial anus or the intestinal  fistula must in most
 instances be  without an eperon. 3d. Frequently, after the destruc-
 tion of the eperon by the method of Dupuytren, the artificial anus
 persists under the form of a fistula which cannot be closed up by any
 means applied.
  a.  An anus without an eperon and resulting  from hernia or a
 wound.—The first description of anus without an eperon comprises
 several varieties.   Thus, in some instances, it originates from a gan-
 grenous portion of the intestine which has been pushed  back into the
 belly before being perforated.   In  other cases, on  the contrary, it
 depends on a rent or laceration of the hernia itself, which has  taken 
HERNIOTOMY OR KELOTOMY.
307
place during the efforts at the taxis, or even at the moment of reduc-
tion.   Again, it arises, after having laid bare the hernia and effected
the debridement,  from our having pushed back into the belly, de-
signedly, or contrary to our intentions, or through mistake, the gan-
grened intestine, with or without perforation, and ulcerated through
and through from the peritoneum to the mucous membrane,  or vice
versa.   In other cases, finally, it results from the intestine which has
been wounded by an instrument penetrating into the abdomen, or
from the operation of hernia, or in any other way, having been left,
or been returned in its place into the peritoneal  cavity.   1st. These
four varieties are  divided  into two very distinct  orders, according
as  there exists or not at  the  same time  a division of the external
parts.  In the first case, that is to say, where the walls of the belly are
laid open, as  after  the operation for hernia, or from a penetrating
wound,  the artificial anus or fistula is established immediately, and
without being necessarily preceded by suppuration or an abscess in
the neighborhood.  In the second case, that is to say, where no solu-
tion of continuity  has been made in the belly, as for example, in con-
sequence of the taxis, a stercoral abscess,  on the contrary, is almost
the  inevitable precursor of an  artificial anus.   Nature  here makes
use  of a process which comprises two elements.  It is necessary, in
the first place, that adhesion should have taken place between the peri^
phery of the intestinal perforation and the corresponding part of the
walls  of the abdomen.  In the second place, there must be an exit
established between  the ulcer and the exterior.  Now  it is immedi-
ately perceived that this last stage of the morbid proofs is infinitely
more complicated  and difficult in the one case than in the other; that
with  the previous opening of the hernia  or through the abdominal
walls, nothing is more simple; while, in the other case, the abscess
which is developed may extend to a considerable distance, gangrene
the parts over a large surface, and ulcerate the skin in a great num-
ber of places.  The intestinal lesions  also under  consideration, are
far from always terminating in the same manner, and their treatment
must be varied according to certain  circumstances.   2d. Wounds
and perforations without gangrene, as in a hernia, for example, may
be reduced and heal up in most instances, without the  intervention
of any description of suture.  The intestine being returned into the
belly, remains behind  the ring and becomes agglutinated to it.  The
parietal  peritoneum agglutinates to the peritoneum on  the borders
of the intestinal opening,  while the  mucous membrane becoming
swollen  and reversed outwardly, shuts up the wound, and  presents
a complete obstacle to  the effusion of  the matters. After  the cica-
trization the patient recovers, with the exception only of some slight
colics or tractions in the neighborhood of the wound.   To the facts
which may be adduced in support of these assertions, I might add two
others which belong to myself.
  A woman  55 years  of age had a  crural hernia which had been
strangulated for the space of four days ; she was brought into my di-
vision at the hospital of La Pitie in 1833.  I proceeded immediately
to the operation, which at first presented nothing peculiar.   A noose
of small intestine  which was seen at the  bottom of the sac, with a
livid tint of a very suspicious character, nevertheless preserved suf- 
308
NEW ELEMENTS OF OPERATIVE  SURGERY.
ficient firmness to banish all idea of gangrene.  After having divided
the stricture, I drew the noose out in order to have a better opportu-
nity of examining it.  We then  ascertained that it was ulcerated in
three places.  Pressure caused  the  intestinal matters to issue out
through the three openings, which were reversed in the manner of
a chicken's rump, (en cul de poule,) distant from two to three lines
apart, and situated  upon the convex  portion of the intestine.  A
probe introduced into one  of them entered freely into  the intestinal
canal.   After having hesitated  a  long time and noticed that these
openings had sensibly diminished in diameter by emptying the intes-
tine, I decided  upon returning  the  latter into  the abdomen.  The
wound was kept open, and the patient maintained in a state of com-
plete immobility.  My fears, I confess, were extreme, but no acci-
dent supervened, and this patient recovered as rapidly and  as per-
fectly as if it had been a case of hernia without  alteration of the in-
testine.   Not the slightest  particle of stercoral matters ever escaped
from the wound, which cicatrized at the expiration of a month, (Arch.
Gen. de Med., 2nd ser., t.  I., p. 595.)
  Another woman  operated upon in the same hospital, in the spying
of 1834,  furnished  me another instance.  This patient, who was 47
years of age, stout,  of an ordinary embonpoint, and in robust health,
had had for a long time an imperfectly reducible hernia.  When I
saw her the symptoms of  strangulation had existed for the space of
24 hours.   Having in vain made another effort with the taxis, which
had already been made trial of under every variety of shapes, I pro-
posed the operation, which was accepted and performed immediately.
Before arriving at  the  sac, it  became necessary to push  aside or
make an incision into several degenerate ganglions.  An adipose lar-
daceous layer then presented itself; a cyst filled with blackish-colored
liquid was the next  that appeared, and exhibited  before us a surface
slightly rugose, bosselated  and resisting, which possibly might be the
indurated sac, and which I proceeded to divide layer by layer, under
the apprehension that it might possibly be the intestine, when a sudden
and  unexpected movement in the patient caused  me to make a com-
plete incision into it to the extent of eight lines.  Mucous dark-colored
matters, and  afterwards yellow  and frothy, immediately  made their
escape through the wound.  The mucous membrane being laid bare
was easily recognized;  my ability to pass the  finger into the belly
through the cylinder I had opened, together with all the other attending
circumstances, satisfactorily proved that the instrument had  entered
into the  ii  estine.   Emboldened by the preceding case,  which was
still  present in my mind, I ventured  immediately to  reduce  the
wounded intestine.   The  wound had  at least eight lines in  extent.
Its direction,  moreover,  was parallel to that of  the intestine, and it
was situated  upon its convex portion.  The most  absolute  repose
was prescribed.  I  placed a linen besmeared with cerate  into  the
crural ring.  The division of the  external parts was kept open by
small balls of lint, and the  rest of the dressing supported merely by a
containing bandage,  and  without any actual  compression.   The
course of the matters was re-established through the anus on the fol-
lowing day, when the vomitings as well as the other symptoms imme-
diately ceased.  None of  the contents of the alimentary canal came 
HERNIOTOMY OR KELOTOMY.
309
out by the groin, and the patient left the hospital in a state of perfect
health on the 35th day.  I have seen her twice since ;  she wears a
precautionary bandage, and suffers only some slight colics when she
has walked much, or eaten more than usual.
  M. Castara, (communicated by the author, 26th Nov.,  1838,) found
six sharp-edged  nuts, in a  strangulated  and perforated  intestine,
which he had cut  into, in order  to extract from  it these foreign
bodies; his patient recovered like the preceding, without any artificial
anus.  It may moreover be readily conceived, that the  result  might
not in every  case be so satisfactory.  The intestinal wound, either on
account of its extent, direction, or form, or owing to the constitution
of the patient, may, should it not close, continue to give exit  exter-
nally, to the matters which pass through the alimentary tube, and be
in this manner transformed into an artificial anus.  3d. If, as happens
quite frequently,  the intestine should be ulcerated, or divided  trans-
versely on one of its points, in the ring for example, the reduction
would present but a slight prospect of cure, and  would scarcely ena-
ble us to hope for the spontaneous formation of a simple artificial
anus.  As the reduced organ continues almost always, in such  cases,
to maintain behind the ring the same relations as in hernia, that is to
say, in such manner that the  portion which was free in the  sac, is
precisely the same which remains opposite to the canal in  the belly,
the following are the results which may happen : 1. The periphery
of the perforation, contracting adhesions with the corresponding part
of the contour of the ring, causes the  course of the matters  to  be
immediately  re-established through their natural route, and the cure
to take place as in the preceding case.   2.  However slightly retard-
ed or incomplete  the adhesions may be, a  certain quantity of matter
will effuse itself into the neighborhood.   This  effusion sometimes
spreads into  the peritoneal  cavity, and speedily causes death.   In
most  cases, it is moderated, confined, and  circumscribed in the iliac
fossa, by means  of the adhesive inflammation of the  surrounding
peritoneum.  In such cases, it is nothing more than  a stercoral ab-
scess, which  in some instances opens at the ring, where it afterwards
terminates in an anus or fistula ; while in other cases it forms  in an-
other place, and in such manner as to make its way into the perito-
neal  cavity,  into  some  hollow organ, or into the substance  of the
walls of the abdomen.  In a patient whom I operated upon in 1831,
in company with Dr. Florence, a collection of this kind  had formed
internally near the bladder, and between the peritoneum and muscles.
Its size was at first so considerable, that wTe attributed it at first to a
retention of urine ;  finally, it made its way into the ring, but  death
did not take place until the twenty-seventh day.  In a man whom I
operated upon in  1836, in the department of M. L'Herminier,  at the
hospital of La Charite, and who died  twelve hours after from peri-
tonitis, the adhesions, though  recent  and  slight, had however been
sufficient to retain the matters in the iliac fossa, and to force them to
take  a  direction, in  part, towards  the  ring, though the  ulcer in
the intestine  was very large, and situated outside of and  above
the crural canal.  I met with a similar case in  a patient of M. La-
croze in J 834, and two others  since at La Charite.  A woman  whose
nernia had become gangrenous at her residence, entered into the 
310
NEW ELEMENTS OF OPERATIVE  SURGERY.
clinical  wards ten days  after, with an  artificial anus.  The course
of the matters was partially re-established, but the iliac region be-
came swollen  and painful.  The finger, introduced into the fistula,
made slight traction upon its outer angle, when more than a litre of
purulent serum, mingled with stercoral and albuminous flocculi, imme-
diately escaped from it; an abscess had been formed there. 4th. When
instead of a solution of continuity without previous mortification, the
intestine is the seat of wounds, or of some gangrenous perforation,
its reduction no longer presents the same prospect  of cure.   If it  is
complete,  and  peritonitis  has not  destroyed  the patient beforehand,
the accidents  will not supervene  until at the expiration of a few
days, an eliminative process being required to detach the eschar.  If
on the contrary the perforation  already exists, at the moment of ma-
king the reduction, we shall know what  to expect in regard  to the
progress of the symptoms.  In both cases, an adhesive inflammation
agglutinates the sound parts,  aroun* those  that  are  diseased.  In
both cases, also, an artificial anus is formed without any difficulty, if
the perforation, whether it  be primitive  or consecutive, corresponds
to the ring. But if the gangrene is situated on another point of the
intestine, we shall  have, in the first case only,  some chances of a cure
without an artificial anus, and in the second, or where both exist to-
gether, an effusion or  stercoral abscess, with  all its consequences, as
in the preceding case.  Whatever may  be the nature of the disease,
the loss  of substance is too decided in a case of gangrene, to allow
us to count upon the immediate closure  of a wound of this descrip-
tion.  It is, nevertheless, remarkable that even  in such cases, the or-
ganism  hastens, so to speak, to confine the disease behind the ring,
by causing, almost immediately, the production of protecting adhe-
sions all around it.  5th. What is here said of hernias that have been
operated upon, is applicable in every particular to  the intestines that
have been wounded at the same  time with the parietes  of the abdo-
men. 6th. An intestine which has become gangrenous or perforated
in any manner whatever, and been reduced by the  taxis, and without
incision of the envelopes of the  hernia, is also placed  in  the same
condition  as in the preceding case, with  this difference, that the anus
or fistula  cannot be established at first, that an abscess must precede
its formation, and that the cure, without effusion or by first intention,
is next  to impossible.  The cause of this peculiarity  is sufficiently
evident from the details I have given, to allow me to dispense with
their repetition.  In a woman who had a crural hernia, which had been
strangulated for the space of three  days, and who was dying from
an extensive peritonitis, when an attempt for the first time was made,
and succeeded  in effecting its  reduction, the intestine, which  was
gangrened and largely perforated, nevertheless continued to be ag-
glutinated to the peritoneum, around the whole periphery of the ring
in the iliac fossa.  In a young man, on  the contrary, who had been
treated in the same manner, an enormous abscess  formed, which had
to be opened upon the inguinal  ring, and in the iliac region, where
the artificial anus was subsequently established. 7th.  Thus, in what-
ever manner the artificial anus may be formed in these various mod-
ifications, it is destitute  of an  eperon,  because the intestine being
placed back in the belly is, so to speak, repaired in the portion of S 
                    HERNIOTOMY OR  KELOTOMY.                311

 which has been destroyed, by means of the corresponding tissues of
 the other organs.
   b. An anus without an eperon, and caused by an ulcer, or internal
 perforations in the intestine.—The intestines are liable to two sorts
 of internal perforations.   In some cases, they ulcerate in fact under
 the action of a foreign body which has become lodged  or retained
 at some point in  their interior ; in other cases, on the contrary, there
 is a true ulceration which ultimately perforates through  the  whole
 thickness of the  intestine.   To the first class belong, the perforations
 caused by the passage of fragments of metal, glass, wood, balls, bone,
 kernels of fruit, &c. To the second belong ulcerations of all descrip-
 tions, especially those from phthisis, scrofula, and dothenenteritis.  1st.
 When the case is one of pure ulceration, produced by a foreign body,
 in a patient who is in other respects  in good health, and where the
 loss of substance is not considerable, such fistulas  generally heal up
 with sufficient promptitude  without an operation; but under opposite
 conditions, it is not unfrequent to see them resist every kind of rem-
 edy, and obstinately continue for an indefinite length of time.
   The annals of science furnish numerous examples  in  support of
 these statements.   The blade of a  knife,  a  fork, fragments of bone,
 &c, have been expelled or extracted through the walls of the belly
 without any fistula being thereby produced. A woman was admit-
 ted  into the hospital of the Faculty, in the department of M. Bougon,
 in 1825, for a pain which she experienced in the right iliac region.
 This pain was accompanied with a fever, and had existed for the
 space of 15 days.   The  stools though rare were always obtained,
 nor  were there any colics.   The whole  iliac  fossa  appeared  to be
 affected, and  the abscess made its  way outward at  the expira-
 tion of three days.  There  was discharged  a large quantity of fetid
 pus, gas, intestinal mucosities and stercoral matters, afterwards an
 angular fragment of bone, which was seven lines in  its small diame-
 ter,  and which apparently belonged to the head of a fish.   The ac-
 cidents afterwards gradually diminished, and in a short time nothing
 remained but a stercoral fistula, which was reduced  to the diameter
 of three or four  lines  in the space of 20 days.  The dressing with
 cataplasms was continued, and the alimentary matters passed in part
 from that period through the natural  anus.  Nevertheless, an injec-
 tion given on the 29th day, again made its way through the fistula,
 which however had entirely closed up on the  43rd.  A permanent
 cure was perfectly established.   I saw the patient four  months after-
 wards and  there was no  return of the disease.   2nd.  When the ul-
 ceration arises from the influence of a constitutional malady, or spon-
taneous inflammation, the fistula  will evidently have less tendency to
cicatrize.   Eugenie Denis, 17 years  of age, without the catamenia,
was  admitted into  the Hospital of La Pitie, on the 18th October,
 1833.  From the  age of 7 or 8 years this patient had been subject to
colic and vomitings. After  renewed  attacks of colic, a painful tu-
mor made its appearance  at the umbilicus.  An incision was made,
when there was  discharged a dark-colored and exceedingly fetid
liquid.  A month subsequently a natural opening was formed below
and to the right, and about the beginning of December four others
were established around  the first.   At the autopsy, both lungs were 
312          NEW ELEMENTS OF OPERATIVE  SURGERY.

found filled with tubercles, and some patches on the intestinal peri-
toneum also contained them.  Besides ancient cicatrices, there were
found also four ulcers in the small intestine.  One of them  situated
in the ileum opened into an ancient false membrane, transformed into
a canal more than an inch long, and in this manner reached the ab-
dominal parietes a  little  above the left inguinal  ring.  It  was by
this route that the matters  had become effused from  below upwards,
and from the left to  the right, in order to reach the umbilical region,
where they resulted in the  stercoral abscess.  In this girl, the species
of accidental funnel, which had formed between the intestine and the
wall of the belly, would very probably have rendered the cicatriza-
tion of the passage  impossible, even though there had been no other
complication.  Nor was there moreover the  slightest appearance of
eperon opposite to the abscess.  Also, she had continued to have her
stools from time to time. I had at the same time at  the hospital, a boy
named Castin, 17 years of age, who had a fistulous ulcer on the right
side and a little below the umbilicus, and from which there was a daily
discharge  of a certain quantity of the contents of the intestines to-
gether with gas.  This ulcer had already existed three months and had
been preceded by an enormous abscess.  The patient, who although
meagre and  puny, had a good deal of  vivacity, and was never with-
out more or less regularity in his stools.  No other organ was found
in a state of disease either by M. Louis or myself.   The probe took
the course  towards the iliac fossa at three inches below, and  to
the right of the external fistula.   I  laid open the whole of this
track in order to establish a  complete parallelism, between  the per-
foration of the intestine and the external wound.  This wound being
dilated  at a  subsequent period by  means of a cone  of prepared
sponge, enabled  me to penetrate with the finger into the  interior,
and to recognize there  all the characters of the caecum and of the
ascending colon.
  Quite a remarkable  phenomenon, moreover, and which we have
frequently seen,  was this, that  at  the same  time  that  we  could
readily make the injections pass  through  the artificial anus, we also
saw  the ingesta by the mouth reach  there almost with the same
promptitude.  However this may be, this fistula, which allowed the
patient to have a natural evacuation whenever it was kept closed  up
by means of a plug of linen, lint, sponge, or even cork, was  trans-
formed into an actual artificial anus as soon as the plug was removed.
There was  no eperon behind.  To effect its  cure  I made use  of
every  description of remedy; and the  simple and quilled suture, and
anaplasty repeated three times all  completely failed.  A small valve
which I recognized at the bottom of the cavity, was removed  by
means of the enterotome of Dupuytren, without any advantage being
thereby produced.   Finally, this young man, who left the hospital in
March, 1834, and in other respects  enjoyed  sufficiently good  health
by his habit of shutting up his fistula with a plug, and whom I again
saw at La Charite on the 15th July, 1836, died of phthisis  in 1837.
The perforation communicated with the large intestine, and the speedy
discharge of the  alimentary matters was explained by a noose  of
small intestine adherent  to  the caecum or colon, and which opened
there, on its side, by means of an ulceration.  In whatever manner 
HERNIOTOMY OR KELOTOMY.
313
we consider this  fact,  it must, however,  be nevertheless  ranked
among cases of artificial anus which persist notwithstanding  the ab-
sence of an eperon.
  c. Artificial anus in which the eperon has been destroyed.—Many
persons would suppose from the writings of Scarpa and most modern
surgeons, that after having removed the eperon of any artificial anus
the cure is  almost certain.   Nothing, however, is  more  incorrect,
and the following is  what Dupuytren himself thinks of it.   From
eight to ten days only, he remarks, are required for the enterotome
to  produce  its effects.   " The stools generally become  regular in
about the same time, but weeks, and even sometimes several  months
are required to effect a complete obliteration of the abnormal open-
ing.  Sometimes, even, it has been found impossible to accomplish
this effectually, even though when reduced to the smallest dimensions
this had become unnecessary, as it could be kept closed for a long
space of time without allowing the egress of the slightest quantity of
stercoral matters.   To  this obstinate resistance of an opening, which
thus  exists without any apparent cause, we have successively op-
posed, and it must be confessed without much benefit, colophane in
powder introduced into its cavity, cauterization of its  borders with
nitrate  of silver, and their approximation effected and maintained by
means of adhesive palsters, finally the excision of these  same  borders
which were formed by the  skin and  mucous membrane, and after-
wards  their accurate coaptation  by means of the quilled  suture."
When we reflect that an artificial anus whose eperon  has been de-
stroyed is placed in nearly the same conditions as an anus or fistulas
from ulceration, or without displacement of the  intestine, we soon
cease to participate in the surprise of Dupuytren.  We soon, on  the
contrary,  ask ourselves the  question, why a cure should  be so fre-
quently-accomplished in  the first  case while it is so rare in the se-
cond.  This is a difference which I have endeavored to discover the
cause of, and which I explain  in the following manner: if the fistula
or  artificial anus is established without an  angular  displacement of
the intestine, there is no membranous funnel formed.  But experience
shows that  an artificial anus without this  funnel is cicatrized with
extreme difficulty.   Scarpa  even goes much farther:  "Artificial
anus  is always  incurable,"  he says,  " when it is formed in conse-
quence of a wound penetrating into the abdomen, attended with pro-
trusion  of the intestine, whether  a part of  this canal  has been  de-
stroyed by  gangrene, or whether it has been  partially or totally
divided by the wounding  instrument."   He  afterwards adds  : " Um-
bilical and ventral hernias almost always give rise to an incurable
artificial anus when they pass into gangrene."  This, in fact, is be-
cause there  is then no hernial  sac which admits of being  drawn into
the belly by the adhesions of the intestine, in such manner as to con-
stitute the membranous funnel  so well described,by the Italian author.
It  now remains to ascertain if an anus which persists, after  the de-
struction of the eperon, might not be ranged under the  same head.
Those cases of artificial anus which are produced by hernia attended
with  gangrene, do not always necessarily lead to the formation of a
membranous funnel.   I am even  disposed to believe that this funnel
is quite frequently wanting.   The adhesions of the sac in the track
   vol. in.                      40 
314          NEW ELEMENTS OF  OPERATIVE SURGERY.
 or upon the periphery of the hernial openings  are sufficiently solid,
 in a great number of cases, especially when the hernia is congenital,
 to resist the tractions made  by the  mesentery and  to  prevent  the
 intestine from being carried to any great distance posteriorly.   The
 destruction of  the eperon, therefore, evidently places the intestine in
 the same conditions as if the  anus had been  formed by an internal
 perforation, or without previous displacement.   It is very natural,
 therefore, that  in other respects  the cure should  be as difficult in  one
 case as in the other.  It is even probable, under such circumstances,
 that after the exsection of the eperon, an artificial anus, in the con-
 dition of a fistula,  will  not heal up unless it  is by a species of perito-
 neal duct or membranous funnel which has become established  be-
 tween the perforation of the intestine and the  external opening.   To
 those who would object  that an  artificial anus, without displacement
 or pre-existing  hernia, will sometimes close up spontaneously, though
 there may have been  no membranous funnel there, I would answer,
 that upon this point Scarpa has again gone too far.  The third case,
 in a memoir inserted  elsewhere, (Journ. Hebd., 1836,) shows us, in
 fact, that  this funnel is possible  after  umbilical hernias;  and we  see
 by the tenth case, that the same may take place after intestinal ulcer-
 ations, proceeding from within outwards, (excentrique;)  only that it
 is to be remarked, in  such cases, that it is a  false membrane which
 has become organized  and transformed into a  canal, and not  the
 peritoneum, which yields or  is elongated into  a funnel; but it is
 easily perceived that this difference is  altogether to the advantage
 of the accidental  funnel.  Thus, on one  hand, the  artificial anus
 without displacement of the peritoneum, appears to require  for its
 cure an accidental membranous canal, which approximates it m char-
 acter to the artificial  anus, properly so  called;  while on the other
 hand an artificial anus  with a hernial sac would, if it persisted  after
 the destruction  of  the eperon, resemble the anus without displace-
 ment, by the absence of  a membranous funnel.   Considered in this
 point of view,  the question  appears to me to  be very simple.  It
 enables us to range every kind of artificial anus that have no eperon
 into two classes, those that  are  accompanied  with a canal or  mem-
 branous funnel, and those that are destitute of this complication.
   d.  Treatment of artificial anus destitute of  an eperon.__Those
 cases of artificial anus that belong to the first class  generally cica-
 trize very well  when they are not kept up by  a vitiated state of the
 constitution, nor by an  organic  lesion  or  any  local  complication,
 such as sinuosities  or separations of the skin, or folding or contortion
of the intestines,  abnormal  adhesions,  &c.   On the contrary  it
rarely happens  that those of the second class do not obstinately resist
the means usually employed against them.  Now it is especially
to the treatment of these last that the following  remarks are appli-
 cable.
  I.  Cauterization and  styptics  are evidently only auxiliary means,
which  are  incapable of  succeeding by  themselves except in  cases
of very small fistulas or  where the anus has a tendency to close  up
of its own accord.
  II. Anaplasty, at first sight, appears to offer a better prospect of
success.  I have made trial of it in three different ways. 
HERNIOTOMY OR KELOTOMY.
315
  a. In one instance I detached the integuments to the extent of an
inch all around  the wound, in order to be enabled to abrade and
approximate its borders with greater facility and to reunite them by
means of the suture.   The stercoral matters soon extravasated  be-
tween the detached  integuments and the other tissues,  notwith-
standing the compression which  I had thought  I could use as a
precaution against this • accident.  It became necessary to  remove
the points of suture on the third day, and the wound was now found
larger after the operation than it was before.
  b. In another instance I cut out  above the ulcer a flap which I
attached in form  of an operculum by means of the  suture to  the
periphery of the fistula, which had been previously  abraded.   On
the second day we noticed a yellowish exudation and bubbles of air
escaping from between the  points of the  suture,  followed  by gan-
grene, which invaded the flap, progressing  from  its borders to  the
pedicle.   M. Blandin,  however, (Acad. Roy. de Med., 1838,) in ope-
rating since upon a patient by this process appears to have obtained
from it complete  success.
  c. The species of plug (bouchon) which I had successfully em-
ployed for shutting up laryngeal fistulas, still presented itself to me
as a last resource. I  borrowed  it from the flank, and after  having
turned it back and doubled  it upon its epidermic surface, 1 inserted
it in the  ulcer and retained it there by means of four points of suture.
An exudation of stercoral liquids took place on the following day.
The suture had cut through the borders of the fistula  and mortifica-
tion of the flap  took place as in the  preceding  case.   The  quilled
suture, morover, without any previous dissection of the integuments,
had been the beginning of all these difficulties.
  d. I thought I could perceive in facl^n these cases that there were
two difficulties to  overcome, one which was imputable to the acrid
or putrescent character of the intestinal matters, and the other which
was caused by the induration of the neighboring tissues.   Though
saliva, tears, serosity, synovia or  even urine may pass  through or be-
come temporarily  lodged  between two points of suture, the  cicatri-
zation nevertheless will take place, provided the contact of the  lips
of the wound has been correctly maintained.   This is because  a
solution of continuity touched, en passant, by any of these matters is
not on that account rendered much less incapable  of the process of
agglutination. The stercoral matters cause an entirely opposite con-
dition of things ; even the slightest particle of these, if it  has become
lodged between the borders of the wound, will prove sufficient to
destroy the tendency to adhesion, and will expose the surfaces which
have been lubricated by it to the risk of mortification.   The different
kinds of  sutures will always find  from these difficulties a serious im-
pediment to  their success.
  e. Fistulas  in general,  and  especially  a stercoral fistula, rarely
continue for the space of a few months without becoming callous.
Its  periphery is transformed into a hard  inodular tissue, which  ulti-
mately resembles  a sort of inorganic ring which is but little  favora-
ble  to cicatrization, either  by first or second intention.  A flap of
pliant tissue borrowed elsewhere and dissimilar in texture will not
agglutinate to it.  To maintain its borders  in contact it is necessary 
316
NEW ELEMENTS OF OPERATIVE  SURGERY.
 to make the suture exercise such powerful  and continued tractions
 that it  must  soon cut through  a tissue  so dense and  so easily
 divided.  Finally, it is almost impossible by the ordinary processes
 that the approximation upon the  intestinal side can be made suffi-
 ciently  exact to escape from the danger of every kind of infiltration
 of stercoral matters.
  III. New Method.—I had arrived at this  stage in the above diffi-
 culties  when there came  to La  Charite a  young  man whom  M.
 Auzoux  had  sent  to me from Normandy.  This boy was nearly in
 the same condition as the  young Castin.  Before proceeding in  his
 case to  any kind  of anaplasty, I resolved upon making trial of  the
 simple suture by the process of M. Raybard, that is to say, to include
 in the nooses  of  the thread a piece of caoutchouc or  pliant wood
 inserted  in the intestine behind the wound, in order to prevent all
 communication of the  interior with the exterior, or to proceed to a
 relaxation of the abdominal walls  by means of two  lateral incisions.
 I commenced with this last process, with the intention of having
 recourse promptly to the other in case of its not succeeding.  The
 operation was performed on the 15th November, 1835.  The cele-
 brated Dr. Mott was kind enough to aid me as an assistant.  I em-
 braced  the entire fistula  in an ellipse, in order to excise  it by a
 double  semilunar  incision, but one which was  to  divide obliquely
 from the sides to the centre, and in such manner as  not to include in
it the intestine or at least not its mucous membrane.   I then inserted
four points of suture at a distance of two lines from each other, taking
 care that their middle portion did not reach as deep as the abdominal
 cavity or the  intestine.   It was at this  point of  the operation that I
made on each  side, at the distance of twelve to  fifteen lines external
to the wound,  an incision two inches long, comprising the  skin, sub-
 cutaneous  tissue  and aponeurosis of the obliquus  extemus.  The
 parts being all washed and perfectly cleansed,  I now knotted the
 threads  and placed a cylinder of lint in the lateral wounds in order
 to keep their  lips apart before proceeding to apply the  containing
 dressing.  On the 18th the matters had accumulated to such extent
 that it became necessary to cut the threads.  The  operation there-
 fore appeared  to have failed ; the borders of the wound were washed '
 and  the patient recommended to  keep them in  as clean a condition
 as possible, while he was kept upon a nourishing diet, but restrained
 as to quantity.  On the 30th December the wound was no  longer
 attended with any discharge except a very small quantity of puru-
 lent  matters;  on the 4th  January, 1836, there  was no  longer any
 discharge of faeces, and the patient was in a very satisfactory condi-
 tion.  He was kept sometime longer at the hospital in  order to be
 certain of his  cure.   As nothing presented itself that gave rise to any
 apprehensions, and as the  patient walked with ease  and was without
 any pain whatever, he was discharged on the 8th February.  It is dif-
 ficult to form an idea of the relaxation which is obtained from lateral
 incisions under such circumstances.  The abraded lips of the fistula
 will then almost come in contact of themselves.   There is no longer
 any necessity of tightening the suture but in the most gentle manner;
 but it is requisite that the incisions should be long and deep in order
 to attain this double object.  The  fistula abraded in the  manner I 
HERNIOTOMY OR KELOTOMY.
817
have mentioned, is transformed  into a species of cup the bottom of
which is perceptibly of less breadth than its mouth.  It results from
this, that we do  not put its cutaneous  portion  in contact without
forcing   also its  intestinal portion to close  up completely.   The
threads  not  penetrating as deep as the intestine, prevent on the other
hand the intestinal matters from  having any opportunity of insin-
uating themselves into the track  of the sutures.   It is probable more-
over, that so far from compressing the belly and  the wound  in the
manner I have done, it would be better to leave them entirely free.
A rigid  diet with repose,  with  a laxative injection  every evening,
during  the  first eight days,  would  also certainly be  more  advan-
tageous.  I  am induced to believe that the accidents which came on
on the third day would not have taken place if I had paid attention
to these circumstances.  Thus in artificial anus without an eperon:
to remove the inodular tissue while respecting the deep-seated or in-
testinal  periphery of the fistula ; to insert the threads without going
as deep as the intestine;  make a long incision the distance of an inch
or two  on  each side; dress without compressing  the  belly;  and
administer a laxative every evening and restrict the patient to a diet;
such, in a few words, is the method which I propose, one which is in
reality worthy of being made trial of whether by itself or in combi-
nation  with it the various descriptions of anaplasty which  I have
already employed.
   [Enterotomy to establish an artificial anus in cases of obliteration
or destruction of the small intestines, as first recommended by Louis
in 1757, and first successfully performed by Renault of Joinville, in
1787, was also recently performed with entire success by M. J. G. Mai-
sonneuve of Paris, (see this case, Arch. Gen. de Med., Dec. 1844, 4e
ser., t. VI., p.  174.)   In a subsequent memoir, (Arch.  Gen., 4e ser.,
t. VII., April, 1845, pp. 448-466,) this surgeon returns to the subject
and  boldly advocates the propriety of recurring to this operation in
cases where the effectual interruption to the progress of the intesti-
nal matters  and  a complete  state of strangulation is  clearly estab-
lished, whether from a foreign body, formation of fibro-cellular bri-
dles or  other  abnormal  growth  in the tube, or by invagination, or
from contraction of its calibre, (sometimes the  result of adhesions
and cicatrices following ulcerations of the gut after its return in ope-
ration for hernia,) or its entire obliteration, whatever the cause may be;
provided enteritis has not taken place or that the alarming symptoms,
tympanitis, stercoral vomitings,  &c, have not resulted in gangrene.
M. Maisonneuve does not  recommend the operation but in extreme
cases, and as the only chance to  save life.   He is aware of its dan-
gers and difficulties, and of the comparatively half-digested condition
of the aliments which afterwards have to be expelled from the artifi-
cial opening before  they can have  possibly supplied  essential  and
proper nutriment to the blood.   This he would endeavor to remedy
by generous food, and where there is  proof that the interruption in
the tube is removed he advises  the anus to be  closed;  for, strange
as it may seem, his experiments on animals establish the fact that the
continuity of the  alimentary canal, after having been  completely ob-
literated by one  or more ligatures, has  by means of an artificial
anus kept open during the time the threads were cutting their way 
318
NEW ELEMENTS OF OPERATIVE  SURGERY.
through the intestinal coats, been again reestablished so that the food
has resumed its natural course, thereby enabling the surgeon to close
up the artificial opening.   This gradual affrontation and agglutina-
tion of  the divided  circular edges of the tube, in proportion as the
ligatures are ulcerating their way through it, is a remarkable fact in
physiology, and  goes to justify  the performance of an operation
which might in some measure  imitate the process of nature.   This
has been but feebly carried out,  however,  in the few and fatal at-
tempts hitherto made in what the French call adossement of the intes-
tines, that  is, a complete exsection transversely of the strangulated
portion  of the gut and afterwards  the restoration of the continuity of
the canal by invaginating the end of the upper over that of the lower
portion  of the gut, &c.   [See the text of M. Velpeau above.]   This
process M. Maisonneuve also approves of as it would seem, but inclines,
we should judge, to the only one he has described, viz: the construc-
tion of an artificial anus externally.  If the fact he states of ligatures
upon  the gut in dogs be exact, the reparative process  here resorted
to by nature should be as exactly  imitated  by art as possible.  But
how to  do this ?   How to institute  this  gradual, slow, certain and
sure process of successive, minute ulcerations, granulations  and ag-
glutinations ?  The author considers that the  tympanitic, distended,
small intestine  above the strangulated part may be diagnosed and
distinctly recognized in its form and course, as M. Laugier had sug-
gested,  provided  peritonitis has not taken  place, the evidence of
which latter will be contradistinguished by the general tense condi-
tion of the abdomen, rendering it impossible any longer to detect or
even  to reach with the touch the convolutions of the gut underneath
the inflation.  M.  Maisonneuve says truly  that the  artificial  anus
should be  as far from the stomach as possible; and  that in most
cases, avoiding meanwhile too much  fingering and searching, (so
often  a source of fatal  mischief,) we may, after the  operation,  know
by the  more frequent recurrence  of the valvulse  conniventes, felt
through the coats of the  intestine, that we are approaching the pylo-
rus, whereas when they are farther apart we are on the ileum.   He
considers this an important point in the diagnosis for fixing a locality
to the new anus to be opened by a slit into the gut.
   Gastrotomy and establishment of an artificial anus, successfully
performed for constipation ; also gastrotomy successfully performed
for constipation from intussusception.—Gastrotomy was  success-
fully  performed by Dr. J. C. Manlove,  (Northern Journal of Medi-
cine,  January, 1846; Boston  Medical  Journal, July  23,  1845;
Proceedings of the  Tennessee  State  Medical  Society,) on  a co-
lored boy 17 years of age.   When Dr. Manlove  first saw him, (July
7, 1844,) he was suffering under some general uneasiness of the ab-
domen  and fever,  and had been  constipated  for twelve or fifteen
days.   Bleeding ad deliquium, and every kind of purgative and in-
jection  almost had been employed without  effect.  On the  10th of
July, the abdomen becoming enormously distended, with difficulty
of breathing, cold  extremities, feeble,  quick pulse, anxious counte-
nance, and no evacuation, the surgeon decided upon gastrotomy, and
the operation was performed by an incision  on the median line from
two inches below the umbilicus to the distance of four or five inches 
                   HERNIOTOMY OR KELOTOMY.                319

towards  the  pubis.  The peritoneum and bbwels along  the lower
half of the incision were found in an intimate state of adhesion, and
in cutting through the former, an opening  of about one fourth of an
inch was made into the latter.  This opening, which appears to have
resulted from a want of proper care in the dissection, proved a for-
tunate accident.   Large quantities of flatus  and liquid faeces, and
some oil of turpentine, which the patient  had taken, were immedi-
ately discharged from it.  On further examination, it was found that
the intestines were united to  the peritoneum by extensive  adhesions
at various points within reach of the finger and probe.   The wound
was closed by sutures and  adhesive straps, except the opening into
the intestine.  The amendment of  all  the symptoms in the course of
an hour was astonishing; the  extremities became warm, the pulse
slower and fuller,  and, during the morning, the patient  was  enabled
to fan himself,  the weather being  excessively warm.   On  the next
day the appetite was good, and he continued Jo discharge the con-
tents of the  alimentary canal  through the ajpificial anus, until the
seventeenth day after the operation, when the bowels acted natural-
ly, as the opening had  nearly closed.  The patient, it appears, had
received an injury to  the abdomen six months before, by  the falling
of a piece of timber.   The boy was well  nine months after the ope-
ration, and exhibited to the society.   The reporter, in adverting  to
the operation under similar circumstances, quotes a case of Dr. Wil-
son, (also of Tennessee,) viz., that of a negro  man supposed to be la-
boring under intussusception, with obstinate constipation, which had
resisted every remedy used. Dr. Wilson then performed the operation
of gastrotomy, and drew the  intestines out of the abdominal cavity,
until he came to the point where the obstruction existed.   About one
inch of the ileum was found to be invaginated and closely united by
adhesions to the receiving portion.  These were dissected loose, and
the bowels returned.  Natural  passages immediately took  place, and
the patient was rapidly restored to perfect health.  It is  curious  in
the above cases, especially in the first, to note the salutary efforts of
nature in forming protecting adhesions.  In  the first, the way was
thus completely prepared for  an artificial anus, and all danger of in-
filtration of faecal matter into  the abdomen or its  parietes avoided.
   M. H. Nunciante is  alleged to have succeeded with intestinal su-
ture in three instances,  (M. Jobert, Arch. Gin. de  Mid., Paris, 4e
ser., t. IX., Oct., 1845, p. 346,)  by  a  sort of spiral or whip (i. e., the
glover's) suture, which by drawing on the two ends of the thread in
opposite directions, brought the intercepted portions of the stitches in
such manner as to place  the serous surfaces of the intestine  in contact,
a point of great importance, and perhaps the only principle upon which
we can reasonably hope for agglutination.  [See text above.]
   The Editors of the Archives Generates de Paris, (4e ser., t. X.,
March, 1846, p. 337,) remarking upon a case  of contracted  colon in
an adult  man  aged 23, in which Dr. Evans, (London Med. Chir.
Trans., vol. XXVIII, 1845,)  in consequence  of obstinate constipa-
tion,  stercoraceous vomiting, and various enteritic symptoms, deci-
ded upon making an artificial anus, by opening into the colon through
the right lumbar region; assert, that this is the eleventh time, as they
think, in which Callisen's process, as modified by M. Amussat, has 
320
NEW ELEMENTS OF OPERATIVE SURGERY.
been performed. Although the digestive functions were in this instance
partially ameliorated, death ensued at the expiration of two months,
from  a violent enteritis,  showing  that this operation (as the other
cases corroborate) does not cure the patient, or at least establishes a
disgusting infirmity in place of the original disease, and is not there-
fore justifiable, but in an extreme case of dangerous obstruction, as
in the patient under consideration,  and where death must otherwise
have inevitably ensued ; the operation under such circumstances pre-
senting the only chance, which, at best, is but  a bad one.
  Enterotomy for Cancer of the Colon—Exsection  of a portion of
the Colon, and cure !—A cancerous tumor occupying the two poste-
rior thirds of the  sigmoid flexure of the colon, occurring in a man
aged 28, and accompanied with  lancinating pains, colics, and much
distension, was, according to  a statement transmitted  by M. Rey-
bard of Lyon, to  the Paris Royal Academy of  Medicine,  but  not
considered by them sufficiently detailed, (see Arch. Gin., Aout, 1844,
4e ser., t. V., pp.  510, 517,) successfully removed by him by cutting
down to  the tumor, and exsecting it, together with a transverse seg-
ment of three inches of the colon, and then uniting the two ends of
the gut by the whip suture.  The cure he says was  complete on the
thirtieth day; if so, it was  almost  the first, if not the only case  of
cure by  enterotomy and  adossement.  But in six months the cancer
returned and the patient died!
   Voluntary Enterotomy and Exsection of seventeen inches of Intes-
tine !—The case related by Dr. Brigham, physician of the New York
State Lunatic Asylum, in which it  is stated, (American Jour. Med.
Sc, April, 1845,)  that a female lunatic, who was a  married woman,
and had had five children, during the  previous two years, suddenly
made, in June, 1843, two wounds in her abdomen  near the umbilicus,
with a large scissors, and tore out and cut off,  that is, exsected a por-
tion or segment of intestine, seventeen inches  in  length, which was
laid aside and  preserved, while the remaining ends were  returned
into the belly, and produced no  pain or uneasiness or inflammation
afterwards, but united and  healed  up internally and externally, fol-
lowed by the restoration of the canal and  natural  discharges, and
complete recovery of health, were  it not for the high character
of Dr. Brigham, would on its very  face be too marvellous  to notice
in this work.  All that we can say is, that it is one  of those narra-
tions which defy all comment.   [See text of M. Velpeau, supra.]
   The Colon opening into the Stomach.—A remarkable case is given,
(London Aled. Gaz., May 2, 1845,)  of a woman aged 64, who, after
the continuance of a protrusion at  the umbilicus  for five years, had
an  abscess formed there, which ultimately caused  a  perforation and
adhesion of the left part of the arch of the colon at its median line
with the stomach, whereby faecal matters were vomited up from the
latter, and ultimately caused death.
   Perforation  of the Ileum—Adhesion of  the  Omentum,  &c.__
A remarkable case is related  by Dr. W. O. Mackenzie,  Dragoon
Guards, Canterbury, Eng., of a soldier, aged twenty-six, who had
been  intemperate, and who had  no other symptoms than moderate
pain in the lower part of the abdomen,  chiefly on the left side, and
obstinate diarrhea, without tenesmus, and more or  less  tympanitis, 
HERNIOTOMY OR KELOTOMY.
321
ending in exhaustion and death.  He  found on dissection that the
great omentum was of a  bright  pink  color, and  lower  on the
right than  on the left  side, notwithstanding the seat of the pain
was on the latter.  The  omentum on the right side, which seemed to
be gathered into a knot above the small intestines, was found closely
adherent  to the ileum,  two  and a  half inches above  its entrance
into the  caecum;  and  in  the  absence of  the  three coats  of the
former intestine ulcerated at this  point, it formed the only imped-
iment to  the entrance of the faeces into the cavity of the abdomen.
This perforation was of the size of a fourpenny piece.  At the same
point, firmly adherent in its whole length, was a large  gland of the
exact shape, but  rather larger than an  ordinary kidney.  It was of
cartilaginous consistence, resisting the  edge of the knife; it was in
the centre of a purple color, but yellowish white  in the other parts,
and it weighed nearly four ounces.  The stomach was so much con-
tracted as to  be concealed  behind the liver.  Peyer's glands were
found unusually numerous  and distinct in  the ileum, and about six-
teen or eighteen inches  from its termination were marks of subacute
inflammation.   At its junction with the  omentum it was enlarged and
very much ulcerated, and diseased until its entrance into the caecum.
Here the appendix vermiformis presented  a singular  appearance,
being of the ordinary size of the duodenum, from the  great thickness
of its parietes; it was nine inches long, pervious throughout, filled
with faeces, and had a  similar  appearance to that described in the
ileum.  Along the whole of the colon, traces of inflammatory action
were well marked, but  least so towards the  sigmoid flexure.  The
kidneys were of the usual size, but of darker color; the mesentery
very thick, no where less than  a quarter of an  inch, besides being
incapable of being  separated into different layers.  Imbedded in  it
were many enlarged glands, varying from the size of a nut to that
of a pigeon's egg.
  The disease, Dr. Mackenzie  properly thinks, must have been of
some years' standing.  The  seat of the pain, as compared with the
morbid appearances, shows how perfectly misled one may be in the
diagnosis, and thus makes the case, in this respect as well  as in others,
of much value.  How nature, secretly at work within, makes her own
anaplastic reparations by these omental adhesions, recalls what  is
seen in  some hernias, and also  in the cases above.  These cases of
pathological anatomy in regions with which surgery  has so much to
do,  especially at this present epoch of the ovariotomy mania for cut-
ting into the abdomen, as well as into the scalp, &c,  without rhyme
or reason, become  exceedingly interesting, and show with the thou-
sand other proofs  how absolutely essential  for correct and  profitable
post-mortem examinations are ample bedside details of the phenomena
before death, and how necessary a previous history of the symptoms
during life, are to the establishment of a sound and legitimate thera-
peutic.  The enlargement of the appendix vermiformis in this case,
says Dr.  Mackenzie, was much greater than anything I have ever
seen before.  I believe the use  of this  structure  has  not been
ascertained.  When I found, he adds, the caecum quite  loaded with
thin faeces, and  the appendix vermiformis  immensely  enlarged,
lengthened, and also distended with feculent matter, the idea struck
  vol. m.                      41 
822
NEW ELEMENTS OF OPERATIVE SURGERY.
 me that it acted as a sort of reservoir, to prevent too great pressure
 against the ileo-cascal valve, whose use is to prevent regurgitation
 into the ileum.   Is such a supposition irrational ? We should answer
 not, but that it is undoubtedly a true one as to the uses of this singu-
 lar appendage.
   We should wish to correct one remark however, which we think
 must be an error in Mr. Irving, who  first attended  the  patient, and
 who, mentioning that his tongue was red, says it was very similar to
 what he had seen in dysenteric patients in  the  West  Indies.  Now
 Mr.  Irving probably alludes to all cases of continued exhausting
 diarrhea like that of the  above case, and  which diarrhea without
 tenesmus, as in  the  case above, and  totally distinct from  dysentery
 and from all its  complications, is marked not only in the  West Indies
 but elsewhere, by that pecular vermilion redness of the tongue (from
the erythema of its  papillae) and in fact of  the  whole mucous  lining
of the mucous  passages,  which is seen also in  the last  stage  of
yellow (not remittent or intermittent) fever,  and in  the last stage of
phthisis, &c.  T.]
                        CHAPTER  II.

                   HERNIA  IN PARTICULAR.

                 Article  I.—Inguinal Hernia.

  Tumors which protrude above Poupart's ligament, between the
antero-superior spinous  process of the ilium and the outer border
of the lower tendon of the rectus  muscle, receive the name of in-
guinal hernia, when  they  are  formed  by  the  displacement of
some  of the  viscera through this  portion of the  parietes of  the
abdomen.  When  we consider the inguinal wall at the interior of
the abdomen, we readily perceive that it is divided into three secon-
dary cavities ; one which  comprises the  posterior opening of the
canal, and is  insensibly prolonged to the  spine of the ilium, the
second which separates the epigastric artery from the remains of the.
umbilical artery, and  the  third which is  found between  this  last
mentioned artery and the termination of the outer border of the rec-
tus muscle.  As hernias begin at  one of these three  depressions, it
has appeared to me advisable to designate  each by a  special name.
Thus, the first may be described under the  title of the external in-
guinal fossa; the second, under that of middle inguinal fossa, and
the third, under the name of internal or vesico-pubic inguinal fossa.

          § I.—The various forms of Inguinal Hernia.

   The external fossa is evidently the point which presents the  least
 obstacle to the viscera; it is by this therefore that hernias must take
 place  with the most facility;  so also are  they  the only kind to 
INGUINAL HERNIA.
323
 which the attention of surgeons was directed up to the beginning of
 the present century.  They are known at the present day under the
 name of external inguinal hernia, a name which Heister formerly
 applied to crural hernia.  When the intestines become lodged in the
 middle fossa,  the hernia takes the name of internal inguinal hernia,
 as given to  it  by Hesselbach.  If they make their escape through the
 internal fossa, an example of which has been seen, as it would appear,
 by Wilmer, M. A. Cooper*and M. Goyrand, (Lancette Franc, t. V.,
 p. 478,) the name which would be  proper to apply to them would be
 supra-pubic   These various kinds of hernia, presenting characters
 and anatomical relations  differing from each other, require each of
 them a separate examination.
   A. External Inguinal  Hernia.—The arrangement in external in-
 guinal hernia is in general easily understood ; the viscera pushing the
 peritoneum before them, become  lodged in the inguinal canal at its
 posterior opening, then pass through its entire length, and then make
 their escape  finally through  the ring of the externus obliquus abdo-
 minis  muscle, in order to descend  subsequently into  the  scrotum.
 When  arrived  at this  condition,  the hernia is complete,  but  it may
 present itself  under other forms.
   I. Supra-inguinal eventration,  (eventration.)—Thus we find, in
 many persons, that the external inguinal fossa allows itself to be re-
 laxed and distended to  so great a  degree that the abdominal organs,
 in pressing  upon it from within outwards, protrude it above Poupart's
 ligament, under the form of a large border, which sometimes assumes
 several of the characters  of a true hernia.   In these cases,  no organ
 having yet in fact entered into the inguinal canal, and the  posterior
 opening of  which has not yet given way, the hernia is incapable of
 strangulation ; it occasions  only a degree of uneasiness and  weight
 which are annoying to  the patient, and which we may find it neces-
 sary to relieve by means of a bandage.
  II.  Incomplete Inguinal Hernia.—In other persons the displaced
 organs reach as far as to the external orifice, but do not escape from
 it, and continue there in the form of a species of cylinder or mass in the
 interior of the canal.  This is a description of hernia which has spe-
 cially occupied the attention of surgeons in our epoch,  but which
 nevertheless had been noticed by several authors in the last century.
 J. L. Petit,  Lecat, Murray and Callisen, appear to have clearly de-
 scribed it.   Scarpa cites a case in which it was strangulated.  Boyer,
 who calls it intra-inguinal, does not consider it as very uncommon.
 M. A. Cooper and M. Key, carefully describe  several instances of
 this hernia.   M. Dance also gives  three cases, and M.  Goyrand  has
 made it the subject of a  special memoir.  It  has also been designated
 by the name of intra-parietal and  inguino-interstitial, but it seems
to me  that  that of incomplete inguinal hernia is more suitable to it
than any  other;  it moreover presents itself under various  forms
which must  not be neglected.
  First variety.—In some cases it occupies exclusively the inguinal
 canal in the shape of an elastic cylinder,  which in the manner of a
 border extends from the neighborhood of the pubis as far as into the
iliac fossa and towards the  corresponding  spine.   I have seen an
 example of this kind. 
 324           NEW ELEMENTS OF OPERATIVE  SURGERY.

   Second variety.—In  other cases  the  tumor acquires so large  a
 volume in the canal, that it is obliged to ascend into the  substance of
 the walls of the belly under the form of a globular mass, or of a plate
 more or less  flattened.  It is  to this  description of hernia that M.
 Dance has given  the name of intra-parietal. under the impression that
 he was the first who had noticed  it, and with the intention of making
 it a new species.                      .
   Third variety.—In other cases again, a portion of the displaced
 organs  escape through  the external ring, while the other portion re-
 mains in the canal.  The parts were in this condition in a case men-
 tioned  by M. Key, and also in another noticed by M. Lawrence.  In
 such cases  the hernia is  generally an entero-epiplocele;  the epiploon
 is  prolonged externally, while the intestine remains within.  This
 was the arrangement in the case of an adult man whom I operated
 upon with Dr. Nicault in 1837.
  Fourth  variety.—In  certain  cases the hernia I am describing is
 caused  by  the imperfect reduction of an oscheocele or bubonocele,
 either  during  the usual taxis or in the operation for  strangulated
 hernia.
  III. Hernias through abnormal openings.—It  is  also possible, in
 external inguinal  hernia, that the intestine, whether situated outside
of the  posterior  ring or in the interior of the canal itself, may make
its escape through a rent in the aponeurosis of the external oblique, in
 place of" passing through the external ring, properly so called.  This
modification of hernia,  the possibility of which is  even contested by
 many authors, is  at the  present day, in my opinion, a fact which has
 been completely demonstrated.   It is even surprising that its exist-
 ence should have been  called in  question, when we reflect upon the
 facts and observations  which have been related, and upon  the man-
ner in which it takes place.   An attentive examination of the inguinal
 region  will soon make it evident that both in the fascia  transversalis
 and in  the aponeurosis of the obliquus externus, there exist two  or-
 ders of fibres which,   by intercussating each  other,  form actual
 diagonal apertures, (losanges,) so much so, that the external inguinal
ring itself is no other than the largest of these apertures.  It is there-
 fore very  natural, that if  from some  anamoly the  ring should be
 found more contracted  than usual, or  if some other of these aper-
 tures of intercussation  should  be found wider, the viscera would
 rather  make their escape  through this  than  through the ordinary
 track.   I would also remark that inguinal hernia, through a rent in
 the aponeuroses, presents several varieties.  It may in fact take place
 through the external inguinal fossa and outside of  the.posterior rin^,
 or through the anterior wall of the inguinal  canal  itself.   I  have
 seen two instances of the first of these varieties.   A  student of med-
 icine noticed in his groin a globular tumor of the size of a large nut.
 It was situated half an inch outside of  the ring ; the fibrous opening
 was founa  immediately above ?oupart's ligament, and  upon a line
 with the crural arch.   The extremity of the little finger  could be
 readily introduced into  it, and it was  easy to  follow the spermatic
 cord as far as the interior of the inguinal canal, and in this manner to
 ascertain that the two orifices were perfectly  independent of each
 other.   The second case occurred at the beginning of the year 1837, 
INGUINAL HERNIA.
325
at the hospital of La Charite.  The tumor, which was of the size of a
small pullet's  egg, was  situated above Poupart's  ligament,  at  an
equal distance from the antero-superior spinous process  of the ilium,
and  from the ring of the  obliquus externus, in which  last I could
easily introduce my finger, while I held my thumb on the abnor-
mal orifice.
  M. Blandin  relates an instance which is still  more conclusive,
since it was demonstrated in the opening of the dead body; a fibrous
bridle two lines in breadth separated the neck of the hernia from the
posterior ring of the inguinal canal.   When the organs have already
entered into the canal they may make their exit in the same manner.
J. L. Petit relates  that he saw a hernia which escaped in this manner,
through a rent in the external  border  of the  ring, (pilier externe.)
Arnault mentions  a patient who had at the same time two hernias,
one crural, and the other a little higher upon the side of the ring, and
both  of which were  only separated by a small fibrous bridle.  A
case of the same kind  has been more recently met with  by M. Roux.
It is well to add, that in  a case which  M. Laugier  showed me, the
intestine, after  having made  its escape  through  Gimbernat's liga-
ment also took the character of a hernia of this description.  It is
also to be remarked, that according to  certain facts related, hernia,
by means of a rent may also take place through the inner border of
the  ring (pilier interne), either directly through the middle inguinal
fossa, or through the  interior of the canal itself.  J. L. Petit relates
an example of this kind,  and another is found in the treatise on ban-
dages by Juville;  but a sufficient number of details are not given to
make these facts conclusive.  Whatever, however, may be the form
of external inguinal hernia which shall present itself, it will always
have the epigastric vessels on  its inner side; whether it be complete
or incomplete  it will, nevertheless, be  found  accompanied by the
close proximity of these vessels at its lower and inner  semi-circum-
ference, provided  it has  entered by the posterior  opening of the
canal; but it is readily perceived that in hernias which protrude at
the outer  half of the external  inguinal fossa, there may  exist a con-
siderable space between  the epigastric  vessels and  the neck  of the
hernia.  When any organ whatever protrudes from the belly into
the interior  of the inguinal canal, it will almost inevitably be found
situated above, and to the outside of the spermatic cord, so long as it
has not yet made its escape through the external ring.   Up to that
point the relations  of the hernia with the canal which  it traverses,
are altogether of a peculiar character, whereas afterwards they are
nearly the same as in the varieties of hernia which remain to  be de-
scribed.
  B.  Internal Inguinal Hernia.—The  viscera, instead of following
the inguinal canal, and of taking a direction obliquely from without
inwards, or from the iliac fossa  towards the pubis  and  scrotum, be-
come  in internal  hernia  lodged in  the  middle inguinal fossa.  This
form  of hernia, obscure]^ mentioned by Camper, and described  by
Cline in his public lectures about the middle of the last century, and
which, notwithstanding, has only been recognized in the character of
a distinct species  of hernia, since the labors of Hesselbach,  is still
designated under the epithet of direct inguinal hernia, or of ventre*- 
326
NEW ELEMENTS OF  OPERATIVE SURGERY.
 inguinal hernia.  Pushing before it the fascia transversalis, which it
 sometimes lacerates between the  epigastric artery on its outside, and
 the cord of the umbilical artery on  its inside, it has a tendency from
 the beginning to force directly in  front of it, and through the external
 ring, the posterior wall  of the inguinal canal.   In this  hemia  the
 spermatic cord is  situated  to the outside, afterwards posteriorly, or
 rather it does not contract any absolute relations with the hernia  un-
 til at the moment when the latter has become lodged in the ring of
 the external oblique muscle.   Without being very uncommon, this
 species of hernia, however, is less  frequent than some modem authors
 seem to imagine.   Up to the present time no special varieties of this
 form have been pointed out;  and  in  fact, unless we admit hernia
 which protrudes through a rent in the  inner border of the  ring to  be
 one of its  modifications, we can see no advantage that  could be de-
 rived in investigating various forms of direct inguinal hernia.  It is
 sufficient that it protrudes through the external ring itself, after having
 become  lodged  in the middle fossa, to entitle it to  the designation
 under which it is generally known at the present day.   As to a her-
 nia  which might be formed between  the  pubic  extremity  of the
 rectus muscle and the umbilical artery, it has not  been  studied with
 sufficient care even in the example related by M. Goyrand, to render
 it  possible at the present time to furnish a detailed description of it.
 Anatomy only instructs us that the organ which is displaced, lacera-
 ting the  fascia transversalis or pushing this latter  before it,  would not
 arrive at the external ring, except by taking  the  direction  of a line
 which would extend obliquely from within outwards, and from behind
 forwards, that is, a direction opposite to that of external inguinal
 hernia.   These  general  relations, moreover, would  differ  but little
 from those of inguinal hernia which  takes place at the middle fossa.
 There would be no difference between them in this  respect, except
 that the epigastric artery, which runs on  the  outer side of internal
 inguinal  hernia,  would  probably be  found at the distance of a few
 lines from  supra-pubic hernia.
   C. Hernia of the Tunica  Vaginalis.—Inguinal hernia, leaving out
 of consideration the aponeurotic canal  that it traverses, presents still
 another variety, which it is important should not be confounded with
 those above; this  is the hernia  which  is called  congenital, because
 some infants have it at  birth, and especially because it is  lodged  in
 that prolongation of the peritoneum which naturally envelopes the
 testicle, that is to say, in the tunica vaginalis.   To  comprehend cor-
 rectly  the  difference which  exists between  this  species of hernia
 vvhich  had already been  recognized by  Mery, and other inguinal
 hernias, we must recall to mind  the displacements which the testicle
 undergoes, in the latter periods of  intra-uterine life
   I. In the foetus, in fact, the testicle  is  at  first  situated  near the
 kidneys  in the  lumbar  region,  and covered, like  all the  other ab-
 dominal  organs, by the peritoneum.  But a bundle  of fibres belong-
 ing to the  obliquus  interims  abdominis  mufcle, and not a cellular
 cord, as has been supposed since the time of Hunter, who designated
 it under the name of gubemaculum testis, insensibly draws  the semi
nal gland towards  the inguinal canal.   In afterwards  descending
into the scrotum, the testicle drags with it a prolongation  of the pen 
INGUINAL HERNIA.
321
toneum in the form of a canal, which is more or less dilated below
the external  ring, and which communicates with the cavity of the
lower belly through the posterior ring. As this serous canal gets more
and more contracted, and finally even becomes altogether obliterated,
from the iliac fossa to below Poupart's ligament, and throughout the
whole  length of the inguinal canal, it necessarily results that in the
adult,  inguinal hernias, of whatever form they may be, take  place
upon  the outside  of, or on the inside or in front of the  spermatic
cord, carrying down with them another portion of peritoneum.   In
the infant, on the  contrary, the hernial organs finding there a cavity
already prepared, become lodged in it in such manner as to be placed
in contact with the  testicle itself.   Congenital  hernia, moreover,
offers  several modifications.   In the most simple cases it occupies
solely  and exclusively the tunica vaginalis, having the testicle at its
inner,  lower, and  posterior side.   In other cases, the testicle having
become arrested at the external  ring, which it appears to close up,
retains the viscera in  the portion  of the tunica vaginalis which is
situated  in the inguinal canal; so that the tumor is then divided, as
it were, into  two  portions, one of which, which  is a sort of incom-
plete  hernia,  and formed by  the viscera, is situated in the canal,
while the other, represented by the  testicle, exhibits itself under the
appearance of a small globular mass situated upon the external ring.
Sometimes, also, the hernia  gets in front, descends into the scrotum
and  leaves the  testicle behind it; sometimes at  the iliac fossa or in
the inguinal  canal, properly so  called, or at other  times at the dis-
tance of some lines only below the external ring.
   II.  In the adult.—From  its title and  the manner in which it is
effected, it would  appear that  hernia of the tunica vaginalis  ought
not to  be  met with except in young children ; this, however, is by no
means the fact.  Inguinal hernia may take place in the tunica vagi-
nalis, and appropriate  this tunic to itself as a sac, at  an advanced
period of life.
   Science, at the present  day, has in  its possession a number of
facts  which  come in  support  of this  assertion, which I made in
1829.   I  have  myself  noticed  several  instances ; among others,
three  which do not  appear to  admit  of the  slightest doubt:  M.
D----, a student  of medicine, twenty years of age, was suddenly
seized  with violent pains in the groin and  a desire  to vomit: these
were caused  by an inguinal  hernia which had just  made its appear-
ance and  become  strangulated.   At the operation, which was per-
formed on the following  day, we found  the intestine in  contact with
the testicle, and  having  no other sac than the tunica vaginalis.   The
most exact statements furnished by the  mother and the  patient satis-
fied us that the two testicles had for a long time occupied their natu-
ral position, and that no hernia had ever existed there.   The tumor
had rapidly acquired the size of the fist.   M. D----, who was rather
somewhat thin than in a state of embonpoint, was  in  the habit of
paying much attention to everything in relation to his' health.   The
second case presented itself in  my department at the hospital of St.
Antoine, in 1829; this was a wine-merchant's boy, twenty to twenty-
five years of age, who, on the same morning, made a  considerable
effort in endavoring to lift a pipe of liquor.  Closely interrogated in 
328
NEW ELEMENTS  OF OPERATIVE SURGERY.
 every wa\, he constantly replied that up to that time he never had
 had a rupture.  This, which brought him to the hospital, was dou-
 ble the size of the fist, and  finally°rendered  it necessary to have re-
 course to the operation.  The intestine contained in the tunica vagi-
 nalis was, as in  the  preceding case, in  immediate  contact with the
 testicle.   Death took place  three days afterwards : we  found on
 opening the body that  the  inguinal canal  had preserved its entire
 length and obliquity, and that the viscera, in order to make their es-
 cape externally, had been compelled to  distend  to such a degree as
 to make  a rent in,  the serous prolongation of the peritoneum,  which
 was contracted,  but not entirely obliterated.
  The third case of this description occurred at La Charite, in 1837.
 This description of hernia,  one of the cases of which was published
 at the time, (Journ. Hebdom., t. VI., p. 267,) was rejected at first as
 a thing impossible.   But Dupuytren,  to whom I spoke of it, and who
 at that time was  also unwilling to admit it, ultimately himself met
 with  certain instances of it.  Many surgeons moreover have men-
 tioned it, without apparently having  any doubt about it.  M.  Roux,
 for  example, saw a congenital hernia, which  took place at the age of
 twenty years.   In the  works of M. A. Cooper, we find  two  facts
 very nearly of the same character.  M. Lawrence cites a boy who
 was attacked with it at the  age of twelve.   M. Lafont speaks of an
 ecclesiastic of about twenty years of age, in whom the testicle had
not  always been situated in the  scrotum, and in whom  there sud-
denly took place an inguinal  hernia, which  became strangulated to
such degree as to require the operation,  and  in which case  also the
tunica vaginalis formed  the sac.  Finally, M. Mayor has published
the  case  of a patient aged  55, who had  to be operated on for  stran-
gulation of a hernia, which had made its appearance at the age  of
twenty-five, and  which was situated in the tunica vaginalis.  To ex-
plain the  formation of a hernia of this kind,  we have only to admit,
as Hunter and Callisen have already done, and as I myself have veri-
fied in many instances, that the tunica vaginalis remains open during
the  whole period of life, or  at least until the age of puberty, in cer-
tain persons in the form of a small canal, and that in some others
even it does not become contracted except at its upper orifice.   In
such cases therefore it is easily conceived that the viscera  may  di-
late its abdominal opening, and  become  lodged in it in mass  as in
the  foetus.
  III. Hernia of the tunica  vaginalis, therefore, presents three varie-
 ties, which are sufficiently distinct: 1st, that  which takes place in the
 foetus or first years of life, and which is congenital hernia, properly
 so called; 2d, that which is  caused by  the  testicle  having  become
 arrested in the inguinal canal, and thereby preventing the tunica va-
 ginalis from closing  up  above, by which means the  viscera  are
 enabled to enter into it, or are even  dragged into it by the testicle
 when it has contracted adhesions with them ; 3d, that which I have
 just described as met with in the adult,  and  the  predisposing  cause
 of which is to be found in the imperfect obliteration of that portion
 of the peritoneum  which is  contained in the inguinal  canal.   In  all
 these varieties, the relations  of the hernia with the spermatic cord
 and the epigastric  vessels, are in other respects nearly the same as 
INGUINAL HERNIA.                    329
in external inguinal hernia, properly so called.  Hey was wrong in
maintaining, and I in allowing myself to adopt his opinion, that in the
child the tunica vaginalis, when the hernia is not vaginal at this age,
is situated in front instead of being behind or on the inside as in the
adult.   In  fact, the tunica vaginalis is sometimes found in front  of
the sac in the adult, examples of which are found in the works  of
A. Cooper, in the same way as it is sometimes met with behind in very
young children.   The name of hernia infantilis, which the surgeon
of Leeds has proposed to give to this variety, in  contradistinction to
that of hernia virilis, w'hich he  reserves for those cases in which the
tunica vaginalis remains  behind, would be therefore  altogether erro-
neous, inasmuch as the two cases of MM. Hunt and Lawrence are
only exceptional.
  D.  Inguinal Hernia in Woman.—The inguinal canal is not arrang-
ed altogether in the same way in woman as in man; it equally offers
as in this last, a posterior and an anterior orifice, but these  orifices
are perceptibly of less dimensions, and the round ligament which takes
the place of the spermatic cord, terminates at the supra-pubic crest,
and does not extend in its totality as  is generally supposed, and  as  I
myself have elsewhere said, to the outside of the ring, to become lost
upon the mons veneris, labium  majus, and groin.  The ligament of
Nuck, which has been compared  to  the tunica vaginalis,  scarcely
reaches in  woman into the inguinal canal.   It is also proper to add,
that the differences of obliquity  in the inguinal canal in a young girl
and young boy,  are not perceptibly more marked than in adult age.
In this respect, Scarpa and modern surgeons have allowed themselves
to be deceived by theory, in place of directly consulting the anatomy
of the parts.  Nevertheless,  inguinal  hernia is quite frequently met
with in women, and must present the  same modifications as in man.
It would even appear, though observation up to the present  time is
silent on this subject, that incomplete  inguinal hernia ought  to take
place more frequently in  woman than in man, to judge at least by the
greater resistance that the organs meet with in attempting to enter
at the apex of the labium majus. In this hernia, the anatomical rela-
tions are the same as  in man, in respect to the umbilical vessels; but
as the spermatic cord is wanting, and  is replaced by an organ of no
great importance in its texture,  and which does  not  descend to the
exterior, it  is readily conceived  that inguinal hernia  in women could
be operated upon with infinitely less danger  than in  man.  I would
add, moreover, that the character of this hernia appears to be yet
very little understood in respect to its anatomical relations.  Whether
it shows itself from the time of infancy, or comes on at another period
of life, it is not positively  known whether the organs drag the peri-
toneum with them into the inguinal canal, or whether they are not
rather, to  a certain extent, drawn into that canal  by a primordial
serous infundibulum.

           §  II.—Parts composing an Inguinal Hernia.

  The viscera which may make up an inguinal hernia are, the small
intestine, transvers ecolon, epiploon, caecum, a portion of the descend-
ing colon, of the  sigmoid flexure of the colon, or of the ascending
  vol. m.                      42 
330
NEW ELEMENTS OF  OPERATIVE SURGERY.
     colon, the bladder, ovary, fallopian tube, a portion of the uterus, the
     spleen and stomach;  even the kidney, a portion of the liver, and also,
     it is said, the doudenum have been found there.  But the small intes-
     tine is the part which constitutes  the  hernia in the vast majority of
     cases:  frequently alone, sometimes associated with the epiploon, and
     in a few exceptional cases with some  one of the other organs  just
     mentioned.
       A. Sac—The sac of inguinal hernia, though formed by  the peri-
   .  toneum as in all other descriptions of abdominal hernia, presents nev-
     ertheless certain peculiarities.   Thus in hernia of the tunica vaginalis
     existing previously to  the descent of the testicles, the arrangement of
     the sac is  such that the testicle as  well as the cord are found buried
     as it were posteriorly  in the  substance of the inner wall of the tumor.
     It descends in such cases a  little  below the testicle, which is found
     naked in its interior when we operate.  If this description of hernia
     occurs in adults, the sac  is formed by a second prolongation of the
     peritoneum, which does not  descend  below the testicle except in a
     few cases, and is separated from  the  tunica vaginalis by a septum.
     In women, the hernial  sac,  constituted in the same manner,  never
     hardly descends as far  down, and presents no peculiarity by which
     we can distinguish congenital hernia from the hernia of the adult at the
     time of the operation.   An inguinal hernia, however, noticed by M.
     Quatreveaux (Soc Anat., 1838,1839, p. 301,) in a woman, descended
     into the labium majus, and was made up of the sac and a superincum-
     bent cyst.  A similar fact is mentioned by M. A. Cooper,  (QZuvres
     Chir., French trans., p. 285.)
      B.  In certain  cases inguinal hernia presents only an incomplete
     sac:  this  happens when it  is made  up of the bladder, the caecum
     or the lumbar  portion of the colon.   When  the bladder  becomes
     lodged in  the  external ring, it is  possible in  fact that this may first
     happen at one of the points  on its anterior surface which is not cov-
     ered by the peritoneum.   It  rarely happens, however, that this cellu
     lar  portion of the surface of the bladder will alone protrude from
     the canal,  or that it does not soon  draw along with it a portion of the
     fundus of  its  posterior region or a part of the side of the organ.   It
     results from  this  that in the first  case,  in incising the tumor, we
     come down upon the urinary pouch without encountering the serous
•   cavity ; and that, in the second case, we come down upon a true sac
     or the bladder itself, according as  the incision may be directed rather
     upon one  portion of  the  hernia  than another.   The hernia of the
     caecum is  the one which in this respect has more particularly occu-
     pied  the  attention  of modern  surgeons.  It is the only one which
     Scarpa is  willing to consider as destitute of a sac, and the one which
     MM. Sernin (Bull, de  la Soc Mid.  d'Em., 1825, t. I., p. 377,)  and
     Colson  have brought forward  in  favor of their doctrine on the sub-
     ject of akystic hernias.   Here anatomy readily explains what expe-
     rience establishes.  The caecum,  situated  in the right iliac  fossa and
     destitute of peritoneum posteriorly, is  attached there by a cellular
     tissue which,  while making  part of the fascia propria, becomes con-
     tinuous with that of the inguinal as well as crural  canal.  This intes-
     tine, therefore, if drawn in any manner whatever towards the scro-
     tum', may pass by degrees by its posterior wall in such manner as to 
INGUINAL HERNIA.
331
descend in this way into the scrotum, either without deviation upon
its axis or  by becoming  turned  round to a greater or lesser extent.
It results from this that  a hernia of the caecum, though sometimes
surrounded almost by a complete sac,  is in  other instances,  so to
speak, destitute of a peritoneal envelope.  It may readily in fact  be
conceived  that the posterior surface of the intestine will also be found
to be situated posteriorly when it forms a portion of an inguinal her-
nia, and that if the operation is performed under such circumstances
the caecum will be contained in a serous cavity communicating with
the interior of the belly.  If on the contrary this intestine has become
turned round while descending, it is possible that its cellular region
may be found to  be  situated upon the inner, outer or even ante-
rior surface ;  and  that unless we have suspected this beforehand, or
shall have  from some cause or other directed the  instrument upon
the actually  serous surface of the  hernia, we might penetrate into
its interior without encountering the sac.  I have had occasion in the
dead body to notice these two descriptions of hernia of the caecum.
In an old woman who was admitted into La Charite in 1836, with a
crural hernia,  and who  died  in  consequence of the operation,  we
found that  the caecum was situated in the inguinal region in the same
manner that it usually is  in the iliac  fossa.   Having diagnosed before
the operation that it was this description of hernia, 1  considered it
proper to make the incision on the inner side of the tumor; but in the
case in question this precaution was unnecessary, as the interruption
of the sac  did not in  reality exist except on its posterior part.   In a
man who was  admitted  into  my department at the hospital of  La
Pitie, in 1834, and who had  an ancient scrotal hernia which  had
already become gangrenous at its upper portion, the caecum on  the
contrary was  so situated that its cellular region corresponded to all
the outer and anterior portion of the tumor.   It was on  the inner
side, and a little posteriorly,  that we had to penetrate, and where,
in fact,  I  made the  incision  in order  to  come  down into the   se-
rous cavity.   Another  portion of  the intestine also is liable to a
certain  extent to  take  on  the arrangement  which  I  have  just
pointed  out, I mean the  sigmoid flexure of the colon.  It  appears,
inPfact, that in certain cases, this intestine has got  lodged  in the in-
guinal canal  in such  manner  as to present its adherent surface to
the inner  side of  the • hernial coverings ;  but the  examples of  this
description of hernia  have  not up to the present time been  detailed
with sufficient minuteness to  make it advisable to dwell  any longer
upon this subject.
  C.  The  other envelopes of  inguinal hernia  scarcely vary in  any
other respect than in  their thickness, and this according to the spe-
cies of hernia which  exists.  Thus, in external incomplete  inguinal
hernia they are composed of  all  the layers  of the walls of the abdo-
men.  The same  remark applies to  complete inguinal or to scrotal
hernia, except that in these the  coverings  are slightly modified  and
generally attenuated.   Underneath  the skin we  find the superficial
sub-cutaneous fascia,  then the dartos muscle, afterwards a prolonga-
tion of the  deep-seated sub-cutaneous fascia, after which we find  the
expansion of the diverging fibres or that of the cellular tissue of the
aponeurosis of the external oblique muscle ; then comes the cremas- 
332
NEW ELEMENTS OF  OPERATIVE SURGERY.
 ter muscle, afterwards the  fascia transversalis, and  then the pro-
 longation of the fascia propria,  which lines  the  outer  surface of
 the sac.
   D. Spermatic Cord.—Whether the hernia be external or internal,
 the number of envelopes is  almost always the same:  but the situa-
 tion of the cord may present essential points  of difference.  Gene-
 rally it is found on the inner  and posterior side, throughout the whole
 extent  in external inguinal hernia.  Nevertheless, the contrary has
 been  several times noticed;  Le Dran, and other  practitioners  after
 him are said to have  found it in front.   MM. A. Cooper and Key on
 the contrary, appear  to  call  in question this entire displacement of
 the spermatic cord, and  do not consider it possible  that there can be
 anything more than  an expansion  of  its various portions.  In this
 respect I differ from them  in opinion.  Whether the hernia takes
 place  in an adult or  is congenital, it may nevertheless admit of the
 cord and testicle being twined round it, either from without inwards,
 or from within outwards, and also from behind forwards.  I  have,
 moreover, so frequently noticed the epididymis and spermatic  cord
naturally arranged in this  way,  when  there was no  hernia,  that I
should be more surprised with the  rarity than  the frequency of its
occurrence in  the  case  under consideration.  Under  such  circum-
stances the position of the testicle, moreover, will suffice to put the
surgeon upon  his  guard, and to  point  out  to  him the precautions
which are to be  taken.  It is, nevertheless, easy to understand, how
the cord when drawn  upon, flattened  and widened, may in certain
 cases leave the veins, arteries and vas  deferens separated apart at a
considerable distance from  each other.   It is in  this way that the
vas deferens especially, though situated upon the inner  side  at its
emergence from the ring, and in front at  its middle portion, has
 sometimes been  found  upon  the  outside of  the  tumor at its  lower
 portion.  In certain cases also, as noticed  by M. A. Cooper and M.
 Goyrand, the  cord, after having  become expanded out posteriorly,
 allows itself to be perforated by the tumor in the  manner of a sort
 of diaphragm,  and afterwards takes a  situation in front of and with
 the testicle below the hernia.  In internal inguinal  hernia, the tumor
 from passing directly through the ring of the external oblique muscl»,
 without being obliged  to pass through the inguinal  canal, would
 rather seem to have  the effect to  push  the cord to the outside, and
 posteriorly, than in any other direction.  This  is what in fact hap-
 pens in most cases when the tumor is  limited to the  condition of a
 bubonocele.   But  when it descends farther into the  scrotum, it  is
 quite  usual to see it cross the front part of the cord, and  to find ulti-
 mately the testicle as well as the vas deferens, behind and on the in-
 side, in the same way as if it were an  external inguinal  hernia.   It
 may be easily conceived also, that this hernia, on the other hand, in
 place of crowding the cord  backwards, might in certain  cases  bring
 it forward rather on  its anterior surface, by making pressure upon it
 from without  inwards, and afterwards from behind forwards.
   E.  In inguinal hernia, the adipose layer which I have elsewhere
 spoken of does not  always  occupy the same tissues ;  in patients
 possessing a great deal  of embonpoint, it may be situated in the sub-
 cutaneous layer in such manner  as to represent a border which is 
INGUINAL HERNIA.
333
more and more attenuated in proportion as it extends in the direction
towards the  scrotum, a border which  is distinguished  from hemia
properly so called in this, that it is actually adherent  to the skin, and
is not prolonged into the inguinal canal.  In other cases the fatty sub-
stance is collected into a mass, sometimes globular and at other times
cylindroidal,  upon the external surface of the sac, and in such quantity
as to form actual tumors, which it  is  sometimes impossible to dis-
tinguish from epiploic hernia.  These tumors, which are denomina-
ted adipose hernias, which have  been pointed out by many authors,
and which Morgagni, and  especially Pelletan,  have more particularly
described, lead to serious mistakes in practice.  Moreover,  though it
be true that  the  different descriptions  of inguinal  hernias when ex-
isting under their most simple forms, may be distinguished from each
other without  any  great  degree of difficulty, it must  be confessed
that in a great  number of cases  this becomes almost impossible.
   F. Many  ancient hernias, for' example, have reacted upon  their
coverings in  such manner, that they descend  below  the inferior ex-
tremity of the testicle, so that they no longer  perceptibly differ from
hernias of the tunica vaginalis.   Also  in such cases they may have
obliterated the  inguinal canal, brought  the two openings of this pas-
sage in front of each other, and no longer present any more  obli-
quity  external to, than upon  the inside of  the epigastric  artery.
Nevertheless, it may be  asserted that every inguinal hernia which
exceeds the size of the head of a foetus has been protruded at  the ex-
ternal  fossa, and  traversed the whole  length of the canal.   Should
the  tumor have been prolonged  in  such manner as to occupy and
distend the entire scrotum, it would be almost useless to seek for any
other proof  of this.  Internal inguinal hernias, and those inguinal
hernias which pass  through a  rent in the aponeurosis, must be inca-
pable of ever  acquiring so great a volume, or of descending to so
great a distance upon the  thigh.   It follows from this, therefore, that
the differential  diagnosis of inguinal hernias  from  each other, must
present less  embarrassment than is  generally believed.  It may be
considered in fact as established, that when they are in the  condition
of bubonocele, the signs mentioned in the beginning of this paragraph
will almost always be found sufficient to  a careful practitioner, and
that when the hernia actually becomes scrotal, it is next to impossi-
ble that there can exist anything else than an external inguinal hernia.
  G. At first sight,  it would seem that an inguinal  could never  be
confounded with a crural  hernia : it would be  an error however to
suppose so.   M. A. Cooper relates the  case of a crural hernia  in a
woman, which  was in this manner mistaken for an inguinal.  A fact
of the  same  kind had been mentioned by Pelletan, who got down
upon the viscera before he found  out his mistake.  A similar  case is
cited by M. Marjolin, and another related from the practice of M.
Roux.   It is in women  especially that mistakes of this  kind are
likely to be  made.   Various circumstances  moreover may explain
them;  in one case there were ancient cicatrices in  the fold of the
groin, which  had forced the crural hernia into a situation in front  of
the inguinal ring.  In other cases, this derangement is caused  by a
relaxation of Poupart's ligament, the presence of an  adipose border,
or the coexistence of lymphatic or other tumors, which  prevent our 
334
NEW ELEMENTS OF OPERATIVE SURGERY.
 distinguishing with precision the point  at  which the hernia sat out.
 In man this mistake may be avoided, by following the course of the
 spermatic cord, inasmuch  as  the  finger,  if this canal  is free, will
 scarcely  ever fail to recognize the ring, whereas, if it  has actually
 served as the passage for the descent of the hernia, it will be  found
 filled up with it.  In women we have not this guide ; from the ring
 being naturally small, and  from there being  no prolongation of it
 whatever to the outside, it becomes a difficult matter in a great num-
 ber of cases to trace its position with accuracy;  M. Nivet has justly
 remarked, that by-first seeking for the spine of the pubis through the
 integuments, in order to proceed  gradually from that point to the an-
 tero-superior spinous process of the ilium, following along the track of
 Poupart's  ligament, we need not have any apprehension of making a
 mistake, it being understood that those hernias  are  crural which  are
 situated below this line, and those inguinal which are placed above
 it;  but Poupart's ligament is sometimes so relaxed and so difficult to
 be distinguished from the other aponeurotic tissues, in  women pos-
 sessing a certain degree of  embonpoint, that this sign, though valua-
 ble  to be  remembered, might  also frequently  lead to mistakes.  It
 may be  moreover readily conceived that, where the hernia has  taken
 place through a rent  in the outer  border of the ring, or in Gimber-
 nat's ligament, or  in the  upper border of Poupart's ligament,  the
 surgeon might be placed in  an  extreme  degree of embarrassment; it
 must be admitted therefore, that in certain exceptional cases, inguinal
 and crural hernias may be quite easily confounded.
  H. If the hernia were constituted of the iliac colon, either on • the
left  side, as I have frequently seen, or upon the right, an instance of
which is related both by Lassus  and Pelletan, if it be not the same
case, we may suspect it from symptoms, which  usually exist in a her-
nia  of the large intestine, and especially from the almost utter impos-
 sibility of making the injections penetrate  beyond a few inches into
the  rectum.    The presence of  the  ccecum in an inguinal  hernia,
 would be indicated by the slow and gradual development of the tu-
 mor, the impossibility of effecting  its complete  reduction, notwith-
 standing the large dimensions of the  rings, the slight  disturbance
 which it causes in the digestive functions, the stercoral  prominences
 which may be sometimes distinguished  through the envelopes of the
 tumor, and by its fixed position in the neighborhood of the ring, even
 though it  may have  already acquired  a very considerable volume.
 The small intestine, on the contrary, gives rise to  hernias, which in
 most cases come on very suddenly, which  afterwards acquire, as it
 were by starts, (comme par  saccade,) their ultimate size, which may
 be completely  reduced while being  accompanied with a  sort of gur-
 gling sound, and which very frequently give rise suddenly to colics,
 constipation, and vomitings.  A hernia of the stomach would be re-
 cognized  by its alternate distension and disappearance, before and
 after a repast, by its  almost instantaneous development at the mo-
 ment after a person has been drinking, by its dull bruit  (matite) un-
 der percussion after eating,  and by  the clear sound which is  emitted
 when the patient has been fasting;  it is in  this  manner, at least, that
 M. Fabre, distinguished it in the case  which  he noticed, and which
 Ml Lebert, (Journ. des Conn.  Med. Chir., 1838, p. 145,) has  since 
INGUINAL HERNIA.
335
completed.  But since anatomical investigation has  already afforded
some light in this respect, inasmuch as M. Yvan, who found  the
stomach in an inguinal hernia in the dead body, does not mention that
it was so recognized during life, it would be advisable in my opinion
not to attach too much importance to such signs. The bladder might
be supposed to be implicated in a hernial tumor, if this last should
usually disappear after the expulsion of the urine ; or should become
distended on the contrary when a long space of time had intervened
since it had been discharged;  or  if the pressure made upon the tu-
mor occasioned pain in the direction of the urethra, and a desire  to
urinate, or if, when pressure was made upon it, it appeared to become
flattened and take a direction towards the  pelvic cavity, instead of
actually re-entering into the abdomen.   As to hernias of the ovari-
um, they might be confounded with certain lymphatic ganglions, or
with some other abnormal tumors;  but  besides their  globular form
and slightly bosselated character, their mobility, the small size of their
pedicle,  and their reductibility, they occasion  in women, when  pres-
sure is made upon them, a pain and sensation which  are so charac-
teristic, that it would be difficult to  make  a mistake in  this  matter.
Hernias of the uterus, apart from the state of pregnancy, have been
too  rarely noticed to enable us to enumerate  their signs.  The same
remark  applies  to hernias of the fallopian  tube, spleen, liver, and
kidney.

            § III.—Complications  of Inguinal Hernia.

  From what precedes, it is perceived that inguinal hernia, when  in
its simple state, may almost always  be distinguished from other dis-
eases ; but this is far from being the case when it is  accompanied  or
complicated with certain conditions.  The complications of inguinal
hernia, moreover, are numerous and varied.
  A. Ancient hernias.—When the inguinal hernia dates to a remote
period, and  never has been reduced, it sometimes acquires a volume
which is absolutely monstrous.  It has been  seen to descend to  the
middle of the thigh, and nearly as far as to the knee.  In such cases
it must be impossible to say, whether it is on  the inside or upon the
outside of the spermatic  cord,  or whether it contains this or that por-
tion of intestine ; it is under these circumstances that we encounter
here at the same time, several of the viscera, the large and small in-
testine, bladder, kidney,  spleen, liver, and  stomach.   The old man
mentioned by M. Fabre,  had a hernia of 90  centimetres in circum-
ference, with elephantine degeneration of the scrotum.
  B.  Adhesion of the parts.—The adhesions in inguinal hernia are
made at the expense of various organs.  In congenital hernia, for ex-
ample, the testicle may become attached to some point upon the epi-
ploon or  intestine.  Various kinds of accidents are thereby produced.
If the external ring is large, the hernia will not return into the belly
without dragging the testicle with it into the inguinal  canal or even
into  the abdomen.  In the contrary case, the retraction of the dis-
placed organs draws  up  the testicle against the borders of the ring
and may thus cause it to be painfully  compressed.   The instances
of this complication are  not uncommon, and Zimmermann himself 
336
NEW ELEMENTS OF OPERATIVE SURGERY.
 was one of the most remarkable.  An  error may take place in these
 hernias, because in epiploic hernias, properly so called, it may happen
 that the epiploon may present itself below as a globular mass, adherent
 to the bottom of the sac.  In this case, if there was only one testicle,
 or if in consequence of a displacement of this organ, it should not be
 found at first, the  surgeon might  mistake the  epiploic tumor for it,
 and thus erroneously suppose that there existed a  congenital hernia
 of the preceding species.   The intestine in issuing from the belly,
 may  become lodged in the inguinal canal by penetrating above or be-
 low a bridle, in such manner as to pass afterwards in an opposite di-
 rection by inclining from right to left, or left to right, so as to become
 speedily liable to  strangulation in this position.   It may, moreover,
 easily be understood, that in such cases two intestinal hernias may be
 formed in the same sac, viz., one in each compartment made by the
 epiploic diaphragm.  In a patient who died at  La Charite in 1836, I
 met with an arrangement of the epiploon which had not hitherto been
 noticed.   This organ existed in the sac in the shape of a cylinder of
 the size of a child's fore-arm, four inches in length, and which was ad-
 herent by  means of some bridles to the  bottom of the sac, and hol-
 lowed out throughout its whole length into* a canal of near  an inch
 in diameter.  It was in this cylinder that the intestine had  become
 lodged and strangulated!
  C.  Secondary degenerations.—These epiploic masses  sometimes
 become, in their turn, the seat of degenerescences.   There are some-
 times formed here, for example, cysts which are  either multiple or
 of the character of hydatids ; in other cases in small number, so as to
 resemble large sacs, as in hydrocele. In such cases the idea of a hydro-
 cele,  either of the  cord or of the tunica vaginalis,  may equally well
 present itself to the mind as that of a hernia, (see Hydrocele.)  Some-
 times also they inflame and become painful, and even the seat of actual
 abscesses.  Should this morbid process be established  in the inguinal
 canal itself, symptoms of strangulation may be manifested  ; only that
 we  could almost always, in such cases, avoid making any mistake by
noticing that the pain is then heavy, deep-seated and  pungent, as in
 phlegmon,  and generally confined to the seat of tumor, that the con-
 stipation is rarely obstinate, that there is rather constant nausea than
actual vomiting, and that  the substances vomited at least do not re-
semble stercoral matters.   Many surgeons have  cited examples of
these kinds of strangulation in the inguinal canal, which have been
mistaken and operated upon for actual hernia.  It may also happen
that without any epiploic hernia,  the cellular tissue in the spermatic
cord will become  swollen in the inguinal canal to such extent as to
constitute  in  that part a painful and hard border, and  to give rise to
some of the symptoms of hernial strangulation, whether a  hernia  has
actually taken place or may never  have existed there.
  D.  In certain  cases  also the adipose matter which lines  the  sac
presents an arrangement which has never been pointed out by any
body, and  which I met with  m one instance  in  March, 1837  at
La  Charite.  After the intestinal  hemia was reduced, there could
be felt through the external coverings several borders,' (bourrelets)
which led to the belief of the existence of some portions of the intes-
•ine or epiploon left in the sac.  An incision having been made  we 
INGUINAL HERNIA.
337
perceived that these bourrelets, which were an inch in diameter and
slightly flattened, were so nearly similar in appearance to the small
intestine,  that we stopped  for some time to examine them, before
knowing what course to take.  Being free and floating in the interior
of the sac,  they appeared  to adhere to this last only by means of a
species of mesentery.  They were composed in reality of adipose
matter, enveloped in a duplicature of the peritoneum, and projecting
in the hernial  sac in a similar  manner to those synovial  pelotons
which are seen in the interior of the articulations, and were, more-
over, continuous with the adipose matter of the fascia  propria.
  E. Inguinal  hernia is frequently complicated with hydrocele, and
this  hydrocele  presents itself under three principal varieties; some-
times  it is  nothing more than the ordinary hydrocele of the tunica
vaginalis, which has  been  produced by the irritation caused by the
proximity of the displaced viscera, or by the pressure made  upon the
track  of the spermatic cord by  the bandages or by the tumor itself.
Without  admitting that  this complication is as common as M. Tes-
sier  thinks,  I feel compelled to confess that it is frequently met with.
In such cases  it may itself become the source of another complica-
tion.  Dupuytren, M. Berard the elder, and some others, have related
facts to me which prove that the hernia enveloped  in its sac  has
occasionally penetrated into  the  cavity of the hydrocele through a
laceration in the  tunica vaginalis,  and become  strangulated in that
position..  In other cases the hydrocele takes place in the sac itself at
the same time,  and in connection with the hernia which exists there.
This is a complication which is  frequently met with, and one which
I have pointed out above.   In  entero-epiploic hernias, after  certain
symptoms of strangulation, we may succeed in returning the intestine
into  the belly; but the epiploon becomes congested and swollen to
such degree that it soon  fills up the inguinal canal.   There takes
place at the same time an exhalation of serosity in the sac below the
ring.  I saw at La Charite", in the year 1837 only, three instances of
this  kind, two  in  men and  the  third in a woman.  In one of these
patients the hydrocele took place under our  observation from one
day  to the next, though it contained eight ounces of serosity.  This
was  a man in whom the hernia, which was also ancient and gene-
rally kept up with difficulty, had become strangulated a great num-
ber of times, but was also always reduced by the  simple taxis.  When
he came into the hospital, it was after the usual taxis had failed, and
the accidents had existed for the space of forty-eight hours.  In the
morning, at the time of my visit, I succeeded in returning the intes-
tine  into the belly; but the  epiploon, which appeared to be adherent,
remained in the sac, and especially in the inguinal canal.   Twenty-
four  hours after, when I  saw the patient again, the symptoms of
strangulation had ceased, but the tumor had acquired  the size it had
the evening  before, and we  were greatly surprised to find it had now
become changed into a true  hydrocele.  I extracted from it eight
ounces of serum.  In the two other cases, the symptoms progressed
precisely in the same manner, except that the reduction of the intes-
tine  had been effected before their admission  into  the hospital, and
when  I visited  them  the hydrocele had been established.   In Feb-
ruary, 1839, I found in the sac of a hernia of this description, the
  vol. m.                     43 
338
NEW ELEMENTS OF OPERATIVE SURGERY.
epiploic mass  in the midst of a thin  stratum  of serosity.  In such
cases we have the signs of an epiploic hernia or strangulation of the
cord in the inguinal  canal, together with those of encysted hydrocele
of the cord or tunica vaginalis.

                   § IV.—Irreducible Hernias.

  Inguinal hernias  are naturally divided into two great classes:
those which may be reduced without any very great degree of diffi-
cultv, and those which are irreducible.   Irreducible hernias without a
strangulation have this pecular feature, whether in the scrotum or else-
where, that it is not  the narrowness of the passages but the alteration
of the displaced organs which prevents their reduction.  Thus hernia
of the caecum  is generally irreducible, because the intestine adheres
to the bottom of the  scrotum.   It is the same in most cases, and from
the same cause, with those of the bladder and colon.   As to epiploic
hernias, they are irreducible  from other causes.  In fact the masses,
cylinders  and  cysts which  are sometimes contained in them, fre-
quently acquire so large a volume that they cannot be made to pass
through the inguinal ring.

                   § V.—-Rupture of the Sac.

  It is  in inguinal  hernia  especially that  we  meet wfth  actual
ruptures of the sac  from external violence.  It may readily be con-
ceived in fact, that a fall upon the scrotum may sometimes rupture
the sac, and at other times some of the organs which are contained
in it.  The kick of a  horse, as in the postilion mentioned by J.  L.
Petit, in the same way  as a blow of any other kind, may produce the
same result.  Such  cases of  rupture of inguinal hernia are not very
uncommon.  Boyer cites an example of one, and another is found in
the works of M. A. Cooper.  MM. Divon  and Plaignant, and  M.
D'Arbefeuille  and  M.  Breidenbach  have published several  others,
without enumerating  those  which are found  scattered in different
scientific  collections, and which relate either  to the rupture of the
vessels, that of the intestine  or epiploon, or to  the rupture of the ex-
ternal envelopes of the hernia itself.

                   § VI.—Hernial Bandages.

   The palliative treatment of reducible inguinal hernia  consists
exclusively in the employment of bandages, vulgarly known under
the name of trusses.
   A. Whatever some practitioners may say to the contrary, inguinal
hernia in children ought to  be kept reducea by trusses as early as
possible.  By means of this  precaution in fact, we may hope that by
the  growth of  the little patient and  the changes which are wrought
both in the thickness of the abdominal walls and in all the oro-ansfto
effect a radical cure in the space of six months, a year, or at farthest
in two years.   Perhaps at this age, in place of the ordinary bandage,
which it  is sometimes difficult to keep properly applied, it would be
well to recur to the method pointed out first  by M. Lawrence  and 
INGUINAL HERNIA.
339
afterwards by M. Meynier, and which consists in attaching over the
ring graduated plates by means of long adhesive plasters, which sur-
round the pelvis and upper part of the thigh.
   B. The pelote of trusses is  generally applied in a manner which xS
but  poorly adapted to the requirements of the anatomical  arrange-
ment of the parts.  Taking its point d'appui upon the border of the pubis
in front of the ring, it leaves the interior of the inguinal canal entirely
free, and consequently presents but a very imperfect obstacle to the
production of  incomplete  inguinal  hernia and strangulation at the
posterior  ring.  Again, the spermatic cord, which is almost always
drawn in such cases to the external border of the ring outside of the
pubic spine, is almost unavoid'ably compressed in such manner as to
render  it incapable any longer of performing  its functions without
much difficulty.  Everything shows, therefore, that a reform is desira-
ble in this respect in the application of bandages.  In recalling what
we have said of the contexture of the parietal walls which are traversed
or may be traversed by inguinal hernias, it will be readily perceived
that a compression which should be made to act on  the entire length
of the canal  in such manner as to maintain its  two sides in contact,
would at the same time be less  painful for  the patient, continued
with greater facility, and possessed of greater efficacy than by the
ordinary method.   In  this manner,  the organs  being prevented from
becoming lodged  in the posterior ring, which  is then as closely shut
up as the anterior, would  allow of the two walls of the sac becoming
agglutinated, and consequently  render the reproduction of the hernia
impossible in a great number of cases.   This is  a suggestion which
was urged a  long  time since by M. A.  Cooper, and which A. Thom-
son  and M. Malgaigne have more recently endeavored to  enforce.
Some bandagists had already anticipated  it; and the pelotes of M.
Fournier de Lempdes, among others, appear to have been constructed
on this  principle.   It is  also certain that many radical cures have
been attained by means of these bandages.
   C. The pelote of the truss ought to make its  strongest  pressure
above Poupart's ligament, at the union of the two outer thirds with
the inner  third of the space which  separates the spine of the pubis
from the  antero-superior  spinous process of the os ilium,  or as M.
Cooper recommends, on the middle of the line which extends from the
iliac spine to  the symphisis pubis.   To render the direction still more
anatomical, I should add that the pelote ought to rest on the  triangle
which is bounded, on the inside by the  expansion of the external bor-
der of the rectus muscle, below by Poupart's ligament, and above by
the lower border of the transversalis abdominis muscle.  1  have no
necessity of remarking that these observations apply almost exclu-
sively to external inguinal hernias,  and  that for internal inguinal her-
nias, or such  as  take place through a rent in the  aponeuroses, the
bandages which are applied directly over the opening  ought still to
be preserved.
  D.  In inguinal hemia of the  tunica vaginalis, it may happen that
the testicle remains in the canal above  the displaced viscera, or that
these latter, while  being reduced, may draw it with them; the appli-
cation of the bandage may in such cases be attended with difficulty.
If by means of judicious precautions it should seem to be practicable 
340
NEW ELEMENTS OF OPERATIVE SURGERY.
to adjust the pelote upon the ring or inguinal canal, between the tes-
ticle and the organs which have been reduced, then  we should not
hesitate to adopt it.   The bandage ought still to be applied  upon the
ring where the testicle has been wholly returned, together  with the
viscera.  If on the contrary the  testicle ascended only as high as
the ring  or could not  in any way be reduced beyond the inguinal
canal, the pressure made upon it by  the bandage would be  attended
with too much danger to allow of its  application.
  E. In entero-epiploic hernias, where the intestine and epiploon ad-
mit of being perfectly reduced, there is no particular direction to be
given in relation to  the application of the bandage;  but should any
adhesions have formed between these two descriptions of organs, and
the epiploon were reducible only in part, we should have to proceed
in the same manner as in congenital hernia.  The following is a case
which was attended with considerable embarrassment:  a filament of
epiploon adhered to  the testicle, and one  could not  ascend or descend
without  the other; the hernia could not be reduced without causing
pain in the testicle, and the testicle could not be placed in its  proper
situation without bringing down the  hernia.   The case of  Zimmer-
mann himself was one of this description.  In  women,  the  bandage
in inguinal hernia is applied with more facility than in man.   The
absence of the  spermatic cord and the anatomical arrangement which
I  have described above, sufficiently explain this difference.
  F. Irreducible inguinal hernias cannot be treated  in  the same
manner  as the  others, by means of a  truss.   If they are large sized
and ancient, the best plan is to enclose them in  a suspensory or spe-
cies of sac properly  constructed, and  which will support  and  make
moderate compression upon them  from below upwards.  When any
of the organs of which they  are constituted is reducible, it should be
pushed back into the belly.   If the portion which remains consists of
epiploon, or does not threaten to become strangulated, we may make
use of a bandage with a concave pelote, which supports and gradu-
ally pushes back the  tumor more  and more against  the  ring.  By
means of suspensories or bandages arranged in this manner, we some-
times succeed  in gradually  diminishing the size  of hernias  which
would appear to be irreducible, and even in effecting  their  complete
return into the belly.  This is what takes place, especially in hernias
of the caecum,  the sigmoid flexure of the colon, the  bladder, and those
which are composed of adipose masses or of epiploon.

          § VIII.—Strangulation of Inguinal Hernias.

  Inguinal hernias are liable, like all others, to the complication known
under the name of strangulation.
  A. Strangulation  spasmodic—An attentive examination of the
fibro-muscular layers of the belly,  shows that the contraction of cer-
tain muscles may sensibly diminish the diameter of the  rin^s  in the
groin as well as that of almost all the other hernial openings.0 It may
for example, be conceived that the divergent fibres (les fibres en sau-
toir), which bridle the upper  angle of the external ring, and  also sur-
round the lower border of Poupart's ligament, would have a tenden-
cy to become straightened under  the influence of the external ob- 
INGUINAL HERNIA.
341
lique muscle of the opposite side, and would thus partially close up
the space which separates the two borders of the ring.  The fibrous
bands which surround the ring, properly so called, approximating
together in the manner of the two borders of a button-hole in order
to pass in front of the symphisis pubis, are also susceptible of being
straightened out, and thus diminishing to  a certain extent the her-
nial opening, should  the  corresponding external  oblique muscle  be-
come contracted.  The fibres which form the posterior ring, arising
almost exclusively from the rectus abdominis muscle, to become at-
tached to the  spine  and  crest  of the ilium, may also be drawn  up,
and thus tend to carry backwards the organs lodged in the inguinal
canal, against the lower  border  of the transversalis abdominis  mus-
cle, which latter also, when contracting, might compress them from
above downwards.  It is therefore evident, that  these muscular con-
tractions may narrow the  openings of the inguinal canal, and that
we should be wrong to look upon the spasmodic strangulation of her-
nias,  as a thing absolutely impossible.  I have demonstrated with the
scalpel  these various anatomical arrangements, first with A. Thomp-
son, and afterwards by myself, in all  subjects which I have had lei-
sure to dissect.  I have  elsewhere published the details of these ex-
aminations, (Anat. Chir., 1837, t. I., Introd.)   M. Astley Cooper,
who  sides with the common opinion, nevertheless admits  the  possi-
bility of spasmodic strangulation by the  lower border of  the trans-
versalis muscle, at the posterior opening of the inguinal canal.
   B.  However this may be,  strangulation in  inguinal hernia may
take place at quite a different number of points.  In some cases it is
at the neck, or the root  of the  sac, and sometimes in the  scrotum
below the external ring.   The first description comprises  strangula-
tion at the posterior ring, and also that at the anterior or  pubic ring
of the inguinal canal.  To the  second variety belong  strangulation
through a rupture of the sac, either in the direction towards the in-
teguments,  as  in the cases above related, or in the septum of a
vaginal hydrocele, as in  the patient of M. H. Berard, or through the
expanded spermatic cord, as has been seen by M. Goyrand.  Stran-
gulation, also, is quite frequently produced by some  appendage of
the displaced  viscera themselves.  An epiploic band, which should
pass in  front of the intestine, as  if for the purpose of dividing it  into
two portions, before  becoming attached to the bottom of the rupture;
or an opening  made in a  layer of epiploon withjn the sac, and through
which a portion of the  intestine has passed, are calculated to pro-
duce  this result.   The epiploon, rolled up into a cord, may become
attached, first on one side and then on the other, making a sort of
bridge, or it may afterwards make another bridge by attaching itself
again on the first wall of the hernial cavity, and react in this manner
upon  the intestine in an  injurious manner.   Two of these prolonga-
tions, after having contracted  adhesions on each  side of the  sac,
sometimes approximate  together in order to  become united a little
lower down,  leaving, in this  manner, between  them a  separation
through which the  intestine may protrude.  I  have  cited a case
where the  epiploon, fixed at the bottom of the sac by means of a
bridle, represented, as high up as the ring, a hard and  hollow  cylin-
der, in which  a noose of the ileum had become strangulated.   Hey 
 342          NEW ELEMENTS OF OPERATIVE SURGERY.

 has figured a scrotum in which we see a portion of epiploon attached
 by its two extremities to the sides of the sac, and presenting in its
 middle portion  a complete  circle, through which the intestine pro-
 truded.   In  a case which I  had an opportunity of examining  after
 death, the strangulation was caused by a mass of epiploon of the size
 of a large pullet's egg.   In a patient operated upon  by Pelletan the
 same result was produced by a tumor of the mesentery.  The ap-
 pendix of the caecum would  nave the same effect if  it should be in-
 cluded in the hernia, and its point had  contracted  some abnormal
 adhesions.  A man forty years of age, whom I operated upon in
 1833 at the hospital of La Pitie, had the inguinal canal dilated to an
 extreme degree ; but the caecum, which especially formed the hernia,
 had  become  turned round to the outside and front, in such manner
 as to strangulate upon the body of the pubis  a noose of the ileum
 which had slipped into  the  bottom of the scrotum.  We may com-
 prehend, moreover, in how many different ways and by what various
 kinds of morbid alterations  a strangulation  of the intestine may be
 produced  in  the interior of the sac.  In respect to strangulations
 caused by the sac itself, they are constituted of different varieties.
 Below the ring  they sometimes depend either upon a rent  in  the
septum, which separates  the  hernia from the tunica vaginalis, or
upon a laceration of the sac; but in  such cases this result most fre-
quently takes place in the contracted portion of an ancient sac.   It
is  necessary  to  recollect, in fact, that  multiple  sacs are scarcely
ever met with except in inguinal  hernias, and that  if one of these
should have remained empty below the new sac, and was still open
at  its upper extremity,  it might possibly  happen that the intestine
would protrude into it in consequence of some  violent effort.   In the
vicinity of the inguinal canal, the sac or its neck sometimes acquires
so great a degree of thickness and so much density, that this of itself
 may cause a strangulation.   In  ancient hernias the agglutination of
their folds augments this thickness to a still greater degree ; various
 lamellae of the fascia propria become attached and adherent to its ex-
 ternal surface;  while the plastic lymph which unites all  these parts
 together, may, in this  manner, bring about a very considerable thick-
 ening of the  sac.  Arnaud states that  he met with  one  which  was
 half an inch  in  thickness, and M. Graefe has since related a similar
 case.  Strangulation  under  such  circumstances may be  so entirely
 independent of the fibraus openings, that we  may succeed in return-
 ing the tumor into the belly without difficulty, but without removing
 the constriction.
   Arnaud and Le Dran were the first to urge attention to this ar-
 rangement of parts, which have since become  generally recognized
 by the exertions of Pott, Scarpa  and Hey.   Dupuytren is one of
 those who has done most to spread the knowledge of  these anatomi-
 cal arrangements among French surgeons.  In such cases the stran-
 gulation may be altogether annular or exceedingly circumscribed, or
 it  may occupy only the entrance or the exit or middle portion of the
 neck,"as it may also the  whole track of this prolongation, and  trans-
 form it into a sort of ring or encasement.  Strangulation at the neck
 of the sac, however,  which,  according  to the school  of  Dupuvtren,
 occurs in eight or nine cases out of ten, or even still more frequently, 
INGUINAL HERNIA.
343
 according to the observations of M. A. Berard and M. King, (Gaz.
 Med., 1829, p. 76,) and which MM. A. Cooper and Lawrence are
 far from admitting in this large  proportion, is in reality quite a rare
 occurrence.  If I venture to place myself in opposition to such high
 authorities on this subject, it is  because I consider that I have dis-
 covered the error by which they have been misled.  The strangula-
 tion in inguinal hernias takes place, as a general rule, at the external
 or internal ring of the canal.   The neck of the sac, properly so call-
 ed, is rarely the seat of strangulation, except in certain ancient her-
 nias.  When it takes place at the posterior ring, if we push back the
 hernia we frequently succeed in making it pass through the external
 ring, and in transforming it from a complete into an incomplete her-
 nia.   During the operation the finger introduced into the canal, soon
 perceives  a movable ring, which may  be  easily pushed back in a
 direction  towards the belly.   In such  cases  it has been supposed
 that  this circle had  been formed  by the neck of the sac,  while in
 reality it is made by the posterior  fibrous ring of the inguinal ca-
 nal.   Nor  do I hesitate  to affirm that in a great number of cases
 attributed to the neck of the sac itself, the  strangulation takes place
 at the orifice in  question.
   C.  The  signs of strangulation in inguinal hernia are in general the
 same as in any other hernia, but they differ somewhat according to its
 nature and precise situation.  At the external opening of the canal the
 strangulation is characterized by a species of tense neck tightened on a
 line with the ring;  by the hardness of the tumor and its fixed position
 immediately below; by its softness and the ability to depress the viscera
 which are placed above or at the iliac fossa; by the pain which is caused
 by the pressure at this point, and also by the impossibility of detect-
 ing the slightest void between the spermatic cord or root of the her-
 nia and borders of the inguinal ring.   Strangulation at the posterior
 ring is distinguished  by other  characters.  Here the organs are ex-
 empt from  any  kind  of pressure at the external ring.   On the con-
 trary we remark  that the species of cylinder contained in the canal
 is tense, elastic and painful.  If the hernia is complete we find that
 under the taxis  it appears to return  through  the  external ring, but
 that it comes back immediately and  without abandoning the  ring
 which strangles it, as soon as the cylinder  of the inguinal  canal is
 allowed to  go back towards the iliac fossa.   This  reduction  is not
 accompanied  by any gurgling  sound, and the viscera only leave the
 scrotum to  augment the tumor contained in the inguinal  canal.
 When the  strangulation  is  caused by the neck of the sac, we  usu-
 ally find the external ring  free, as in the preceding case; but  the
inguinal  canal itself is no more distended than in strangulation by
the anterior opening  of the canal.   If the tumor appears to return,
it is for the purpose of becoming lodged  in  the fascia propria under
the peritoneum  of the iliac region.
   Strangulation in the interior of the scrotum would be distinguish-
ed in  this  way, that  while the rings, as well as the canal appear to
be free, the hernial tumor, nevertheless,  continues irreducible, and
also by the fact, that the most  painful  point in such cases,  is not
either  at the  posterior  or at the anterior  opening of the  inguinal
canal, but in reality in some part of the scrotum, properly so called. 
344          NEW ELEMENTS OF  OPERATIVE SURGERY.
As to the mode of ascertaining, under such circumstances, whether
the strangulation is produced by a laceration of the sac, a rent in the
tunica vaginalis, or by some bridles or perforation of the epiploon, or by
a contortion of the intestine, or by the neck of some ancient sac. this ap-
pears to be a point utterly impossible.   The distinction of the different
kinds of  strangulation in inguinal hernia is reduced, therefore, nearly
to the following points:   1st, We may decide whether the obstruc-
tion  exists below  Poupart's ligament, or  at  some one point in the
parietes  of the abdomen; 2d, in  this last mentioned region it is fre-
quently in our power to avoid confounding a strangulation at the ex-
ternal, with one which may be  produced at the internal  ring, and
these two last  with a strangulation caused by the neck of the sac.
It is  well  to remark, however, that symptoms of strangulation in  in-
guinal as well as in any other hernia, must present modifications ac-
cording as the hernia is found to be composed of this or that organ.
Thus, in  hernia of the caecum, as the course of the matters are not
obstructed, except at a very advanced period of their elaboration, nor
scarcely  ever entirely intercepted, it rarely happens that the vomiting
and constipation at first are as marked as in  hernias that are purely
intestinal.  If the hernia in question  is one  of the appendix only  of
the caecum, as in a case related by M. Bougon, (Bull, de  la Fac de
Mid.,  t.  V., p. 248,) and  in  that of M. Taramelli, it  is  difficult to
understand how there could be  produced by it symptoms of an ac-
tual  strangulation.   M. Taramelli, however, affirms, that in the pa-
tient  he  operated upon  successfully, all these symptoms existed.
Mery also speaks of a hernia in which an appendix analogous to that
of the caecum appeared to have been strangulated ; but as there was
a strangulation  also of  another portion  of  intestine, it would  be
Wrong to conclude from this case that the accidents were exclusively
referable to the appendix.  M. H. Larrey (Revue Med., 1830, t. IV.,)
has seen  one of these diverticuli near the ring, and  another similar
Case was shown to me in 1838.   The sigmoid  flexure of the colon
is to be considered with the same restrictions  as the  caecum; nor  do
the bladder, ovarium, womb, spleen, kidney and liver appear to be of
a nature  to give rise to either constipation or  vomitings of  stercoral
matter.  I would make the same remark of the epiploon and the tes-
ticle, of strangulation of the cord, and of adipose tumors and inflam-
mation of the  sac;  so that  in inguinal  hernia,- as in any other,  an
insurmountable constipation with stercoral vomitings, positively indi-
cate a strangulation or obstruction of a portion of small intestine, or
of a noose of the  colon.   Mistakes,  moreover, in a case of inguinal
hernia, are almost  always  owing  to other  diseases, which have
effected an alteration upon the seat of the lesion.  If, for example, a
man affected with hemia in the groin should be attacked with symp-
toms analogous to a cholera,  as was  seen in the case of M.  A. Vidal,
or in that of M. Briquet, the surgeon would naturally be induced  to
believe that it was a case  of strangulation.  An inflammation in the
ihterior of the sac, or the transformation of  the sac into  an actual
abscess,  causing a revulsion, as has been seen  by Dupuytren,  M.
Duparcque and M. Key, sometimes either  on the viscera, which
have not  been reduced, or upon  the  peritoneum, intestines and
stomach, to such degree as  to  bring on vomitings and constipation) 
INGUINAL HERNIA.
345
 would in the same way lead to deception.  So also strangulation and
 inflammation of the epiploon, testicle, or cord in the interior  of the
 canal  or sac, might equally give rise to error; but a mistake  would
 almost always be avoided by recalling to mind what I have said
 above.  Strangulation in inguinal  hernia being clearly ascertained,
 there exists an obvious necessity of removing it as speedily as  possi-
 ble.  All the rules and remedies pointed out in speaking of hernias
 in general, are especially applicable to inguinal hernia in particular;
 so that there is no necessity in my  dwelling in this place on the sub-
 ject of bleeding, nor of leeches, baths, purgatives, tobacco injections,
 acupuncture and galvanism, nor  of the various  topical applications
 which have been successively extolled under  such circumstances.

                       §  VII.—Operation.

   The operation for inguinal hernia is performed at every period of
 lite.
   A. In Children.—It would be erroneous to suppose that it is never
 required in young children.  Pott and other authors had  already
 remarked that enterocele might become strangulated and cause death
 in  the first months of infancy.  M. Denonvilliers has communicated
 to  me another proof of this:  A child, eight months old, died with
 symptoms of peritonitis, when upon opening  the body it was discov-
 ered  that death had been caused by a strangulated inguinal hernia.
 M. Heyfelder operated for hernia  in an infant  that was  only eight
 days  old, and  Dupuytren  upon another that was twenty days old.
 The one cured by M. Hunt was twenty-nine days old, and of the
 two cited by M. Goyrand,  one was four months old and the other
 six.   M. Lawrence operated upon one fourteen months old,  and the
 hernia was not  congenital.   The case of M. Long was that of a child
 of the same  age, while M. Hildebrand's was eighteen months.  Out
 of these eight operations, five at least were successful.  It is readily
 to be conceived also, that strangulation at this period of life is  easily
 confounded with most of the diseases of the lower belly.   In a male
 child, fifteen months old, whom I operated on at  La Charite, in 1837,
 the hernia was complicated with  hydrocele.  The want of exact in-
 formation, the cries of the infant, the condition of the scrotum, in fact,
 every thing conspires, in such cases, to render the diagnosis  obscure
 and difficult.  As  to the operation, properly so called,  it is evident
 that, from the indocility and want  of reason in the little patient, it
 must necessarily be extremely difficult, and require a degree of cau-
 tion, both in respect to the manual or the subsequent symptoms, which
it is far from so imperatively demanding in adults.
  B. In  Man.—As the integuments in general preserve a certain
degree of pliancy at this point, it is almost always practicable to take
up a fold of them for their incision without being  under the necessity
 of stretching them, as is done in making a simple incision.
  I. Incision.—Whether we adopt, moreover, this or that method,
 it is advisable that the incision should extend  to a half an inch or an
 inch above the ring, and  that it should descend, unless there should
 be some special reason to the contrary, as far down as to the bottom
 of the tumor, following its greater axis.   This incision requires some
   vol. in.                     44 
346
NEW ELEMENTS  OF OPERATIVE SURGERY.
precautions.  From the spermatic cord not having  a fixed position,
we might  be  liable, in certain cases, to wound the vas deferens or
spermatic artery, as happened in two instances to Hey.  In external
inguinal  hernia, it has been  seen to  pass in front of the  tumor in
such  manner as to be found upon the outside when it reached the
lower part of this last.  I have  seen three examples of this in pa-
tients who each had an enormous hernia.  In internal inguinal hernia
the same thing  may happen, but  in an inverse sense; that is to say,
that the spermatic cord placed externally at its emergence from the
canal, may come gradually in  front and then on the inside, then
unite  with the  testicle which  is below, and also  on the inside.
There can  be  no doubt  that in cases of this description, the instru-
ment  would almost inevitably wound one of the parts which make
up the spermatic  cord, as  must have  easily happened  in  the cases
related by Schmucker,  Camper, Le  Dran, Boudou, M.  Fardeau,
Scarpa, A. Cooper, Lawrence, Blizard and  some others.   The tis-
sues therefore which separate the integuments from the sac are to be
incised with caution.   The division  of  these intermediate layers
moreover is to be made according to the rules we have laid down in
the beginning.   When the inguinal hernia is direct, the incision of
the integuments is to be parallel to the axis of  the body.   When on
the contrary, the tumor is  external and not of large  size, it must be
oblique from above downwards and from without inwards ;  but when
the hernia is very large it will be  found advisable to give the incision
a very elongated semilunar form, with its convexity looking upwards
and inwards.
  II.  As to the sac, if it should  present no  inequality, it would be
most prudent to perforate  it below, in front, and slightly to the  out-
side.  After having laid  it open freely above,  as  high up as  the
ring, the  question then is to be  asked whether it  is  indispensable to
prolong this incision  completely down to  the bottom of  the  sac.
Some persons consider the contrary the correct course.  Hey among
others, as well  as Scarpa, from an apprehension of wounding the tu-
nica vaginalis, which lies in this direction, recommend that we should
leave  below a half an  inch at least of the  sac undivided.  In reality
it is almost a matter of indifference whether we adopt either the one
or the other of these methods.   When we have  to operate upon a
congenital hernia, the organs having enlarged and distended the tu-
nica vaginalis below the testicle, present in this respect two formida-
ble difficulties to be avoided.  If the sac is opened throughout its whole
length, the  testicle constantly tends to escape from the bottom of the
wound, and may thus give rise to accidents.  If we incise the serous
pouch only in its upper half, we shall find it  much more easy to re-
strain the testicle, but  the  pus, if it should form, will become accu-
mulated  in the cul  de sac preserved below, and thus give rise to
other  serious symptoms.   The best course therefore would  be to
make a large opening, and be satisfied with afterwards  bringing the
borders of  the tunica vaginalis in front of the testicle, and  in  main-
taining them there by  one or more points  of suture.
  III.  To remove the strangulation.—Owing to certain vessels which
it is important  should not be wounded, inguinal hernia presents  one
of those cases in which it would be most advisable to have recourse 
INGUINAL HERNIA.                     34'7
 to dilatation, if this method were at all practicable.   Theory lays it
 down that the  debridement, the only resource employed  at the pre-
 sent day, should be performed by this or  that process, according as
 the case under consideration is this or that form of bubonocele.
   a.  For example, for those hernias in  which the neck is situated ex-
 ternal to the epigastric artery ..that is to say, for all those which have
 passed through the iliac opening of the inguinal canal, the debridement
 is to be made to the outside, on one of the points of the external semi-
 circumference of the ring.  On the contrary, to the inside for inter-
 nal inguinal hernias, and directly upwards when there is an epigas-
 tric artery on each  side, as  in  the  case communicated to me by
 Lauth.   These different  indications explain why such opposite rules
 have been given  on this  subject by  the  most respectable authors.
 Sharp, La Faye, Pott, and Sabatier recommend  that the debride-
 ment should  be upwards and outwards, because the epigastric artery
 is usually found upon the inside ; Verduc, Garengeot, and Heister, on
 the contrary, recommend that it should be made to the  inside, and
 Bertrandi, who saw a case in which the debridement was outward,
 cause a hemorrhage by the division of the epigastric  artery, ending
 in the death of the patient, gives  the same  advice.  Finally, it was
 from the dread of finding this  artery upon the one side or the  other,
 that  J. L. Petit,  before Rougemont, Autenreith, Cooper,  Scarpa,
 Richerand, and Dupuytren, who  followed the same practice,  ad-
 vises that  the  stricture  should  be divided  directly upwards.   It
 is true  that  Desault  and Chopart had already  remarked, that  the
 artery is upon  the  inside when the spermatic cord is found poste-
 rior to  or upon the  inner side of the tumor, and that it  is upon
•the outside in the contrary case.   But to arrive at a definite opinion
 upon this subject,  there  was wanting the anatomical  knowledge
 which exists at the present day.
  b. To  lay  it down  as a rule that we should divide the stricture
 outwardly when the hernia is external, and inwardly when it  is in-
 ternal, could  be a  matter of no  importance, unless there were less
 difficulties in distinguishing those two varieties of the disease from
 each other.   Moreover, when  there are two epigastric arteries, or
 when the only one which exists arises from  the obturator at a cer-
 tain distance from the external  iliac, it  might very naturally be
 found upon the  inside  in internal inguinal  hernia, as it is usually ob-
 served to be in external inguinal hernia, in  the same way that the
 external  epigastric artery in the  case mentioned  by Lauth might
 have been situated outside of an oblique inguinal nernia.  It was
 precisely owing to this uncertainty that MM. Cooper, Scarpa, Riche-
 rand, and Dupuytren, prefer  the method of  Petit or Rougemont.
 By incising directly upwards they remark, that it is a matter of lit-
 tle importance whether the artery be  upon the outside or upon the
 inside, whether there be  two  of  them or one only, or whether the
 hernia be internal  or external, as  we have no hemorrhage to dread,
 for the instrument  always divides the tissues parallel to the  usual
 direction of the vessels.  An objection however which exists is this,
 that the epigastric artery, in place of following a line parallel to the
 axis of the body, is directed obliquely from without inwards, and
 from below upwards, in  order to reach the umbilical region,  while 
348
NEW ELEMENTS OF OPERATIVE  SURGERY.
passing above an internal inguinal hernia; while in an external in-
guinal hernia, I have seen it depressed so much to the  inside, that it
formed, so to speak, a semicircle, the upper extremity of which might
have been very easily wounded in a  perpendicular incision.   As it
rarely fails to be displaced by the root of the tumor,  we  cannot in
reality ascertain whether it  is vertical rather than oblique, in  one
direction or another.
  c. I will, remark that in internal inguinal hernia, the pubic  branch.
furnished by the epigastric, would almost inevitably be wounded,  and
that in cases where its great  size  was abnormal, an alarming  hemor-
rhage might result from this,  as appears to have been the fact in two
cases noticed  by M.  Lawrence.   No method therefore effectually
protects us from hemorrhage.  Nevertheless, the epigastric artery is
but rarely wounded.  From whence does this happen ?  In the first
place,  because this artery, from  being pushed back by the neck of
the sac, is almost always situated  at the distance of two or three lines
from the constricting circle, and that in most cases we do not give a
greater extent to  the incision  than this.   In the second place, we
escape the artery because, in the  strangulation caused by the  ring of
the external oblique,  the incision is made upon a circle too  remote
from the artery in question to incur any apprehension of our wound-
ing it; from whence it follows that after rigidly examining this mat-
ter, it  is found that the debridement may be made in any direction
without danger, provided we do not give it too great an extent, and
that the successful results obtained at Vienna  at the beginning of  this
century by Rudthoffer, who  always divided  the stricture upon  the
inside, after  the manner of Bertrandi,  present nothing remarkable in
this particular.   If we add  to  this that internal inguinal  hernia is a
rare occurrence, and  that in our days the debridement outwards is
preferred in the great majority of cases, we may readily comprehend
why hemorrhage, as a consequence of kelotomy, is so  uncommon an
occurrence.   Nevertheless, as it has been noticed in several instances,
attention is still required on the  subject of the means to be employed
to avoid it.
  d. The author.—In every strangulation  at the inferior opening of
the canal, the debridement,  whether made by means  of  a convex
bistoury, guided upon the pulp of  the finger, as Bell recommends, or
what would be better still, by making  use  of the point of a straight
bistoury, also protected by the finger, or of a blunt-pointed bistoury,
which incises from the free border of the ring towards  a point more
or less remote from its circumference, would  secure us from every
danger, inasmuch,  as  by following these  directions, the instrument
does not penetrate as far as the posterior surface of the fascia trans-
versalis.  To glide the bistoury of Pott, or the  common blunt-point-
ed, or in fact any straight bistoury whatever, into the ring, in order
to divide its internal border  near its  lower  attachment, and trans-
versely from without  inwards, is  a  still  more easy and certain
method.   I have  found  that we  could in this manner  divide  the
stricture without danger, as largely as was  desirable.   In  the other
cases, the repeated divisions, whether by means of the hjunt-pointed,
straight, or with the curved bistoury, inasmuch as one  or  two lines
of depth only are  sufficient  to  each incision, are, if I am not  de- 
INGUINAL HERNIA.
349
ceived,  calculated, in whatever direction they may be made, to ren-
der the  lesion of the epigastric artery a thing almost impossible.
  IV. If in spite of all these precautions, the artery should have been
wounded, two instances of which were related to Gunz at Paris, the
evidence of which was established on opening a dead body by Ber-
trandi,  and  by the  cases related  by  Richter,  Le Blanc, Hey,  A.
Cooper, Scarpa,  Lawrence, M.  MacKay,  &c,—what  is to done ?
M.  Lawrence states  that he found the epigastric branch completely
divided in an individual operated upon for strangulated inguinal her-
nia, but in whom death took place  from another cause.   In a second
case the hemorrhage was suspended in consequence of syncope, and
the patient was  perfectly restored. But  the  question to be ascer-
tained is, whether the blood in this case really did make its escape
from the epigastric artery.  I myself have seen in the dead body of
a patient, who died in consequence of a penetrating wound of the
abdomen, an  entire  division of this  vessel, the hemorrhage  from
which had been quite inconsiderable, and had ceased spontaneously.
It might be  possible, therefore, that a wound of this description might
repeatedly occur, without the surgeon being conscious of it.  A lig-
ature applied, as recommended by  Bogros, upon the root of the artery
itself, or through the interior of the wound, by means of the various
instruments proposed by Arnaud,  Schildner, Richter, Desault, and
many other practitioners, would be attended with too much difficulty
in its execution, and offers too slight a prospect of success to justify
our attempting it.   It is  better to pass  beyond the ring a sort of
chemise or  small sac of fine linen, the bottom  of which has been
filled by soft lint, in order to  constitute  it into  a tampon, by means
of which we afterwards make compression upon the parts from be-
hind forward, or  from the peritoneum  towards the  integuments.
This is  the process which Hey and Boyer adopted in the successful.
cases related by them, or which are given upon their authority.
  V. Reduction.—The  best mode of effecting the reduction of the
liquids or matters enclosed in the  intestine,  is to embrace the whole
mass of this latter with  the palm of the  hands, and to make gentle
pressure upon  it, until it is almost entirely  emptied.   It is  at the
groin particularly that we should be on our guard not to force the
viscera  in  between the  peritoneum and  the fascia transversalis,  or
into the substance of the parietes of the abdomen, for it is in this de-
scription of  hernia that Le Dran, Callisen, La Faye, Sabatier, Pelle-
tan, Lassus, Hasselbach, M. Delmas, M. Lawrence, and  myself have
noticed   the accident I  have mentioned.   Nor do we anywhere
also so  often  find  bridles  behind  the ring, caused  by  an  adhesion
of the appendix of the caecum, a prolongation of the epiploon, or an
accidental band, &c.  It was at that part also, that Hey found the
sac divided  horizontally by the epiploon  into two distinct pouches,
one anterior, containing only serum, the  other  posterior and enclos-
ing the  intestine.   There  is scarcely perhaps  any anomaly "What-
ever, or any of the  degenerescences of the digestive  organs, or the
epiploon, which has not been found in inguinal hernia.   This is the
variety, moreover,  which has presented those appendicula, in the
form of fingers of a glove, which  have been noticed by Ruysch,  F.
de  Hilden, Mery, Littre, and  M. H. Larrey, as well  as by myself, 
350
NEW ELEMENTS OF OPERATIVE SURGERY.
and which were connected with a point more or less higher up upon
the ileac portion of the intestine.   When the inguinal hernia is an-
cient, and of excessive volume, as it is  rare  that the  displaced vis-
cera, under such circumstances, have not contracted adhesions with
each other, which are difficult to  be destroyed, or that  they have not
in some respects become agglomerated together, in such manner as to
represent in certain cases a mass  purely fleshy,  an attempt at reduc-
tion in such cases is not always advisable.  If in such cases the
hernial envelopes have been divided  throughout their whole extent,
we confine ourselves to returning the  free  portions into the belly,
while the rest is left externally ; the whole is then covered with com-
presses, saturated with emollient  liquids, which, with  the horizontal
position to  be preserved by the patient, will gradually bring  back
the organs as far  as to the ring, if not even into  the  interior of the
belly itself.
   VI.  It is in this modification  particularly that Ravaton,  Monro,
Boyer, Scarpa, and MM. Cooper, Crawther and Lawrence recom-
mend, as J. L. Petit did, that we  should divide the stricture without
opening the sac,  after the method which  M. Raphel  supposes he
had  invented, but which he had only combined with a  suggestion of
Bell upon debridement in general. In such cases therefore we make
an incision of some inches in length at the root of the tumor, in order
to arrive gradually upon the neck of the sac without opening into it.
A canulated sound is immediately introduced between  this neck and
the ring, which latter is  then divided in conformity to  the rules laid
down above. As soon as the strangulation is destroyed, the reduction
is  to be undertaken immediately,  if the  viscera can be pushed  back
into the belly without its being attended  with too much  difficulty. In
the contrary case we confine ourselves to returning those which
readily yield to our efforts, while the remainder are  supported or
kept up by a suspensory or a bandage, which is to be arranged in a
proper manner.  If, after having divided the  ring, the  strangulation
should  continue, we should perforate the neck of the  sac and  then
introduce  into this  opening  a  blunt-pointed bistoury, and divide it
with the usual precautions.  In ordinary cases  after the organs are
reduced, the sac is sometimes so movable  and so little adherent
that  we are enabled to detach it as it were, and to gather it  in
mass, as Garengeot says, to impact it  in the ring or to excise it.
Without  recurring again  to what I have  said  on this method in
the preceding pages, I cannot omit remarking that if we decide upon
adopting it in inguinal hernia, we ought at  least to assure ourselves
previously of the situation occupied both by the vas deferens and the
spermatic vessels.
   VII. Another method still has been proposed  for inguinal  hernia,
viz:  that of M. Colliex.  The  incision is made from the exterior to
the interior, from the beginning to the end of the operation, in  such
manner as to divide  the sac  completely in  the  same  way as the
skin.   The incision in the first place is directed upon the whole length
of the inguinal canal, in order to open into the sac on a line with the
external ring ; but this kind of incision, which presents no advantage
and  which  immediately strikes  one by  its dangerous  character,
was doubtless suggested in  consequence of those serious accidents 
INGUINAL HERNIA.
351
which are no longer possible at the present day.   No one in- fact at
the present time has any apprehension of wounding the intestine in
seven cases out of ten, but which  M. Colliex states he has  seen in
many hospitals, (Revue Aled., 1834, t. II., p. 20.)
  VIII. When the case is one of strangulation in the scrotum itself,
there is no need of making the incision of the hernial  envelopes as
high up as has been mentioned, but it ought to descend lower down.
If on the contrary the case is one of incomplete  hernia, the incision
ought to be  made  to reach from the outer third of Poupart's ligament
down to the root of the scrotum only.   In this case our object is to
divide successively the two layers of  the sub-cutaneous fascia, the
aponeurosis of the external oblique muscle, some of the fibres of the
internal oblique, and finally the entire anterior wall of the inguinal ca-
nal. In inguinal hernias strangulated by the posterior ring, the incision
should also be prolonged upwards  to a great extent; but if they are
not incomplete, it  is advisable to prolong the incision moreover to a
point sufficiently near to the extremity of the lower part of the tumor.
If the case is one of hernia of the tunica vaginalis, we ought to avoid
as  much  as possible giving this extension to the opening of the sac
below, inasmuch as  the testicle, after the reduction, would have too
much tendency to escape from its position. In cases of hernia of the
caecum, the bistoury should rather be directed upon  the inside than
upon the outside of the tumor.   After the sac moreover is laid open,
we ought, should the viscera be found adherent or incapable of being
reduced in consequence of the age of the hernia, to confine ourselves
to destroying the obstacle to  the progress of the matters, to keeping
the belly in  a depending position, and to bringing back gradually the
displaced organs towards the ring.  (See Hernia in General.)
   IX. Upon  the  supposition  that we have operated in  order to
remove the difficulties  produced by a strangulation of the spermatic
cord, there would, after the  debridement was  effected, be  nothing
more to do.   In cases of hydatids  and  adipose tumors we must have
recourse to  the excision of the morbid  parts, and  the same must be
done in respect to lymphatic  ganglions, if any of these should chance
to be developed in the inguinal canal.  A more embarrassing case is
that in which the testicle is present in the interior itself of the ring.
It almost always happens in  such  cases that the testicle is changed
either in its conformation or  structure.  If it is  excised the patient
finds himself deprived of an important organ; if we confine ourselves
to the removal of  the strangulation and the testicle cannot descend,
the same accidents  may be  reproduced.  Before the operation it
would be so much  the more difficult  to  pronounce with. certainty,
inasmuch as a true hernia in a person with but one testicle (chez urt
monorchide) may manifest itself in  the place of the one gone, an
example of which  has been met with by Fages.   It remains therefore
for the practitioner to determine by the arrangement of the parts and
the particular  circumstances in which the  patient is placed, the
course which  it is most advisable to pursue.
   X. As to the mode of dressing and  the treatment  subsequent to
the operation, they should be based upon the same principle as after
the operation  for hernia in general.  I would only add that there is
no operation in which immediate union presents  fewer advantages or 
352          NEW ELEMENTS  OF OPERATIVE SURGERY.
       exposes to as many inconveniences as it does in strangulated inguinal
       nernia.   It is true that it succeeds sometimes, as the practice of M.
       Serre and that of the English surgeons sufficiently establish the fact;
       but  the transformation  of the sac into a vast abscess, leading  to a
       supposition of the reproduction of the  hernia and producing  effu-
       sions of pus into the belly, and those cases of erysipelas and purulent
       collections  mentioned by authors, and  especially by M. Key, what
       are they imputable to unless to those attempts at union by the first
       intention ?  In cicatrizing the wound by second intention we avoid
       this description of accidents, and we have moreover, as I have men-
       tioned, a possible chance of closing up the hernial  canal  radically.
       If after the operation of inguinal hernia, the inflammation and  the
       suppuration ascend along  the cord  towards the  supra-pubic canal,
       spreading  under the skin of the iliac region rather than in  the direc-
       tion  towards  the thigh or perineum, this result is owing to the fact
       that the sub-cutaneous fascia, which is very adherent below, becomes
       thinner and thinner as it ascends  upon the abdomen.
         C. In woman  the operation for inguinal  hernia is attended with
       but very little  difficulty; and we  proceed moreover in  the same
       manner as in man, except that we have nothing to fear from the lesion
       of important organs before we reach the  sac.  From the absence of
       the spermatic cord the only thing to be attended to in these cases is,
       to respect  the intestine and the epigastric  artery,  which  moreover
       are avoided by means of the precautions mentioned in speaking of in-
       guinal hernia in man.   If in this hernia the  ovarium should be found
       to be arrested at the ring or to have descended into the labium majus,
       examples of which have been  related  by Priscien, (Peyrilhe, Hist.
       de la Med.,  p. 715,) Veyrat, Pott, Lassus, Haller, Lallemand, M. De-
       neux, and M. Cruveilhier, (Arch. Gen. de Med., 2e ser., t. IV., p. 275,)
       prudence would suggest, however slightly the accidents may appear
       to be connected with  its presence in the ring, that we should  pro-
       ceed to its  removal.   The uterus, fallopian  tube and bladder should
       be reduced in the same way as the intestines, or  would not fail to
       become subsequently reduced of themselves.
          [Inguinal Hernia.—Sir Astley Cooper was so fortunate in one of
       the last cases that received  the aid of this  illustrious surgeon, as to
       effect the cure of an artificial anus  resulting from  the mortification
       of the gut of an inguinal strangulated hernia, which suddenly made
       its appearance  in a woman aged thirty-four, at the third  month of
       her  pregnancy,  and for which the surgeon operated.   The fecal
       matters, which at first flowed  through the wound, soon resumed their
•      natural course, when the parts healed up  kindly.   (Provincial Med.
       and  Surg. Journ., April 15, 1841.)
          Radical  Cure of Inguinal Hernia by the Seton.—Dr. Moesner
       (Medicinisches Correspondent Blatt, in the Journ.  des Conn. Med.-
       Chir. de Paris, Janvier  1, 1846, p. 28,) has  already obtained a radi-
       cal cure of inguinal hernia in four cases, by the following process:
       he raises up the scrotum and  sac by means of a thread, introduced
       on a species of sonde a dard of his invention, which is  a curved
       canula, mounted on a hollow handle, and  terminated by  an olive-
       shaped  button of the size of a pea, and which  is also hollow.   By
       means of a stylet adapted to the  curvature of the instrument, and a 
CRURAL HERNIA.
353
needle, furnished with a thread, which he can pass through the olive
button, he causes the skin of the invaginated scrotum, and also the
inguinal canal and the skin of the belly, to mount up into the interior
of the canula.  The thread, having  been introduced with the precau-
tions necessary to avoid wounding  the viscera, is left  in the wound
to perform the duty of a seton, and not for the purpose of retaining
the invaginated scrotum, as in  the methods denominated those of in-
vagination.   The inguinal canal is then compressed and the patient
kept in bed  eighteen to twenty days, a period usually sufficient to
cause an adhesive inflammation of the whole canal, after which the
thread is withdrawn.   The  compression is  afterwards continued as
a precautionary measure, by means of a truss, for some weeks.
   Large Reducible Hernia.—Mr.  Bourne, of Bath, (Eng.)  success-
fully operated for inguinil reducible hernia on the right side, of very
large size, which had existed for fourteen years in an old sailor aged
seventy, paralyzed on  that side.  The firm and old adhesions of
thickened omentum to the sac, allowed of no other resource for the
strangulation than the operation.  (Lond.  Med. Gaz.,  May,  1846,
pp. 882, 883.)
   New species of Inguinal Hernia.—At the sitting  of the  Royal
Academy of Medicine of Paris, December 8th, 1840, (Arch. Gen. de
Med. de  Paris, 3e ser., t. X., 1841,  pp. 107, 108,) our author,  M.
Velpeau, exhibited an anatomical specimen  presenting a new variety
of inguinal hernia, which authors have not mentioned.  The intestine
instead of descending through the inguinal canal, has made a passage
for itself through an  aponeurosis,  between  the  outer  border of the
rectus abdominis muscle and the umbilical canal. T.]

                  Article  II.—Crural Hernia.

   Crural hernia has hardly been distinguished from inguinal hernia
except since  the time  of Barbette, Nuck and Verheyen.   Its natural
seat is the fold of the groin, and the opening which admits of its pas-
sage, is known under  the name of  the crural ring or canal.

                         § I.—Anatomy.

   The crural canal, constituting a  communication between the inner
side of the iliac fossa  and the inguinal depression,  represents a sort
of funnel, the base of which would be situated in  the pelvis and its
point on the thigh.  Its upper  opening, measured transversely, has a
diameter of about  two inches,  and  in women frequently two inches
and a half.  From before backwards, in its greatest diameter, it has
but from ten  lines  to an inch, when it afterwards becomes narrowed
as we  recede  from its middle portion.  In its natural state it is
divided into two portions  by the crural vessels,  in such manner that
from the iliac fossa we should reach it through two small fossae,
which I would denominate  crural fossettes, one internal, the  other
external, and which  must not be confounded  with  the inguinal
fossae, which I have mentioned farther  back.  Its  internal portion,
which is the largest, forms what has  been specially described under
the name of  the crural ring.   Its  limits on the inner side  are  the
   vol.  in.                    45 
354
NEW ELEMENTS  OF OPERATIVE SURGERY.
  concave border of Gimbernat's  ligament;  in front, Poupart's liga-
  ment ; behind, the ilio-pectineal crest;  and  on the outside, the crural
■  vein, the  artery of the  same name, and the  epigastric artery.   It
  usually contains a lymphatic ganglion separated from the vessels by
  a sort of partition, a prolongation of the fascia propria, and some adi-
  pose cells which almost  completely close  it  up.   It is this crural ring
  which gives passage to  the viscera in crural hernia.  Also its exter-
  nal portion is triangular;  in its ensemble, then, it constitutes a large
  and nearly elliptical opening, formed above  by the abdominal branch
  of the ilio-pubic band, below by the iliac branch of this same band and
  by other intercussating  fibres.   Its internal angle is rounded off by
 Gimbernat's ligament, while its external angle continues quite acute.
 The femoral vessels divide it into two unequal halves.  In the direc-
 tion of the thigh this  opening  is continuous by means of a  fibrous
 expansion with the whole extent of the crural canal, under the form
 of a cone, the  apex of which terminates upon the external tunic, of
the vessels, on a line with the entrance of the saphena into the crural
vein.   The walls of the crural  canal are formed  by the  femoral
aponeurosis.
   Viewed  on the outside this aponeurosis  is  found to be wanting;  its
superficial layer passes in front of the crural vessels, and assists, where
it attaches  itself at its  apex very near the supra-pubic spine, in con-
tributing to the formation of Gimbernat's  ligament.   It is triangular
or falciform, and one of the borders, viz., the superior, is attached to
Poupart's  ligament.  Another,  which  is  the  external border, is  its
point  of origin.  The third, representing a species of arcade, cir-
cumscribes the upper and outer part of the inguinal opening of the
fascia lata.  The inguinal opening of the crural canal, the internal
and lower half of which resembles rather a  gutter, has an oval form
with its large extremity outside or below,  and  its point  at the exter-
nal border  of  the ring of the obliquus externus muscle.   Viewed  in
the direction of the pubis, this opening is turned round at first into a
semicircle to the outside  and below, in order to mount up  afterwards
from without inwards, and then from below upwards, as  if its point
of termination was about to glide under its place of origin ;  in such
manner, in fine, as to form in its totality a  spiral convolution, and  to
make its axis fall obliquely from  within outwards, upon the antero-
posterior axis of the thigh.   As lamellar tissues, which are a  sort of
attenuation of the fascia  lata, fill or shut it up in quite a solid manner,
many observers have been  induced to  believe that  it does not in re-
ality exist; but in taking the saphena for our guide we always meet
with it, provided we leave out of consideration the reticulated mem-
brane or species of cribriform layer which conceals  its  shape.   The
posterior wall of the crural canal is formed by the deep-seated layer
 of the fascia lata.  Its external side, which  is about two  inches and
 a half long, and oblique from above downwards, and from without in-
 wards, is made by the separation of the two layers of the fascia lata.
 Its internal side, which  does not, properly speaking, exist, extends
 only  from the pectineal crest, or Gimbernat's  ligament, to below
 Poupart's ligament.  The notch of the superficial layer  of the apo-
 neurosis replaces it in this direction.   Its  lower orifice  leaves un-
 covered a portion of the vein, and  incloses deep-seated lymphatic
4 
                         CRURAL  HERNIA.                      355

 ganglions, and especially cellular  tissue, which unites the  sub-cuta-
 neous fascia to the sub-peritoneal fascia.   This canal, which is  an
 actual continuation of the iliac fossa without the viscera, peritoneum,
 infundibulum and fascia propria which occupy that, passes under the
 internal half of the femoral arcade, and is directed towards the thigh,
 forming a passage, whose anterior wall is to a great extent wanting
 in order to receive  the saphena vein, and  ultimately becoming con-
 tinuous below with the sheath of the  sartorius muscle.   It  is thus
 easy to comprehend how matters effused into the abdomen, between
 the  peritoneum and  the  aponeuroses, may be  transported into the
 groin, produce an infiltration of the limb, and give rise to abscesses
 by congestion, which might mislead to the supposition of  a  hernia or
 some other tumor.

                 § II.—Formation of the  Hernia.

   From the space which exists  between  the  superior spine of the
 ilium and that  of the pubis being  more considerable in women than
 in men, femoral hernia is  much more common in the first sex  than in
 the other.   Another anatomical reason powerfully contributes in in-
 creasing  this  relative frequency of crural  hernia  in women.  The
 inguinal canal, which is  very  narrow in this  sex,  has no scrotum
 which prolongs it to the exterior.  The viscera being incapable of
 making their  escape through  this, as in men,  are on the  contrary,
 thrown back into the crural fossette of the iliac  region, and  come out
 with more facility through the femoral canal.
   I. The  hernial sac, already lined by the fascia propria, in passing
 through the crural canal crowds before it  and  appropriates to itself
 the greater portion  of the cellular tissue  which  it  finds there, and
 even envelopes itself with  it in  leaving the sub-cutaneous  fascia,
 and  for the same reason pushes downwards,  inwards or  outwards
 the lymphatic ganglions, which in certain cases it merely raises up,
 and  which in  this manner continue to rest upon  the tumor.  The
 hernia being once formed, has a  tendency to  be  directed towards
 the external and  superior part much more than  in an opposite di-
 rection, which is owing to the greater adhesion of the sub-cutaneous
 fascia inwardly, or upon the outside and below, than in the direction
 of Poupart's ligament.  This  has existed  to  such  a  degree that
 crural hernia has been seen to be directed  in this manner  as far as
to two  or three  inches in the direction of the  os ilium.   Instances
of this kind have been related by Arnauld and M. Larrey.  The sac
runs along the inside of the femoral vein and artery.  At its  upper
portion  it  is in connection with the origin  of the epigastric  artery,
which crosses its  anterior and external portion.  In man it is crossed
obliquely by the spermatic cord, from which it  is separated only by
Poupart's  ligament.
  The epigastric artery may take  its origin at an  inch or an inch
and a half higher than usual, as it may also be given off by the fem-
oral  artery; from whence it happens,  that in the  first case, this
branch might be pushed back to the inner side of the hernia in place
of remaining outside of it, and that in the second case, the  debride-
ment on any point whatever of its external half, would almost inevita- 
 856          NEW ELEMENTS OF OPERATIVE SURGERY.

 bly divide it.   A second varietv, which is more remarkable, is the
 one which I have already indicated, and in which the epigastric ar-
 tery is seen to arise from the obturator, at more than an inch distant
 from the external iliac, as has been  noticed by M. Hesselbach and an
 instance of which I have also met with.   There can be no doubt that
 in this case the crural hernia would be found upon the outside, and
 the same  thing would take  place if the vessel in question took its
 origin  from the hypogastric, as I  have seen  it do.  A much  more
 dangerous arrangement still would exist if the hernia should form in
 persons who have at the same time  two epigastrics, one originating
 from the iliac and the other from the  pelvic artery, as was seen in
 the individual  whom I mentioned above.   In  man  especially, the
 neck of the sac would then  have the pelvic  epigastric on its in-
 side, while the iliac  epigastric  would  be on its  outside, and the
 spermatic  cord in front.   Another anomaly  is the one, for the
 knowledge of which we are indebted to M. Michelet, that is, where
 the internal circumflex  of the thigh arises  from the epigastric it-
 self.  The artery in this  case might be found in  front of the  body
 of the  hernia, cross  it obliquely from without inwards,  and reach
 the abductor  muscles of  the thigh.   But  the variety  which is
 most frequently mentioned, is that in which  the obturator and epi-
 gastric arise by a  common  trunk from the  external iliac.  It is in
 fact the most frequent. The examinations which I have had it in my
 power to  make of it on several  thousand dead bodies, either in the
 hospitals, amphitheatres of dissections, or at the school of practice, do
not permit me to assert that it is met with in  one case out of three or
 five or even ten, but only once in every fifteen or twenty instances.
 It is an arrangement, moreover, which is much more simple than is
generally  supposed.  Before birth, the obturator artery arises almost
constantly by two roots, one from  the hypogastric,  the  other  from
 the epigastric.  But by  the law,  the epigastric root is soon oblitera-
 ted, while the  hypogastric continues, and forms in fact the vessel.
 When  the contrary takes place, the anomaly in  question is noticed.
 Many practitioners have supposed that in such cases, the neck of the
 crural hernia would have the epigastric artery upon the outside, and
the obturator in front  and within, in  such  manner as to be  almost
 completely surrounded by an arterial circle.   Even if this were pos-
 sible, it would  at least be  a very rare  occurrence.   These arteries
 take their respective position a long time before the  period of any
 hernia  whatever.   As the  epigastric  trunk is placed  between the
 peritoneum and the fascia transversalis, or the ligament of Poupart,
 the obturator, should it arise from it, would be necessarily situated
 in the  substance of the fascia propria.   To reach the  infra-pubic
opening, it would be necessary that it should follow the lower  semi-
 circumference  of the  crural ring.   The viscera in  escaping, and
 thereby necessarily crowding it  backwards almost unavoidably, do
 not appear to incur any risk of bringing it upon their  anterior sur-
 face.   Up to the present time, moreover, I am not aware that there
 is any positive evidence from examinations of the dead body, that
 it has been wounded during the operation, though many persons have
 stated that this result has taken place in those who continued to sur-
 vive.   For the reason alone, that the iliac  artery on arriving  at the 
CRURAL HERNIA.
357
 ring, divides this opening into two halves, and that the epigastric ar-
 tery is given off from its inner or anterior side, there must necessarily
 exist a point which has but  little resistance upon the outside of the
 latter vessel.   In directing the finger on this point, we soon perceive
 in fact that it is possible to pass by that route from the interior to the
 exterior of the belly, from whence it would appear to result, that her-
 nia  might sometimes take place  on the iliac side  of the epigastric
 vessels.  We  might therefore admit the  possibility both of an exter-
 nal and of an internal crural hernia.   An instance has been related
 by M. Cloquet, and another  was shown to me by A. Thompson.  It
 is true that Arnault, and the greater part of the pathologists  of the
 last century, together  with  Sabatier and M. Walther, do assert that
 the  intestine in coming out of the abdomen, passes  from without in-
 wards, over the anterior surface of  the crural vessels, and they  con-
 sequently leave it to be inferred that the epigastric artery remains on
 the  inner side  of the neck of the sac; but on this point they confine
 themselves to bare assertions, and there is no evidence to show that
 they have positively ascertained the fact by dissection.
   II.  Femoral hernia is not enveloped in as many tissues  as bubono-
 cele.   We find here nothing more than the peritoneum, the fascia
 propria, the fascia superficialis, and the integuments.  Moreover, it
 is in that intermediate layer  which  lies between the skin and serous
 envelope,  that we meet  with those lymphatic ganglions, sound or
 diseased, hypertrophied, indurated, or congested in any  way what-
 ever, or inflamed or in  a  state of abscess, with those hydatid cysts
 and those inflamed and cold or  congested  abscesses, which some-
 times  surround a crural hernia, in such manner as to render its diag-
 nosis so difficult and the operation so  delicate.   It was  in this  part
 doubtless that the pus accumulated in the two cases of cold or  con-
 gestive abscesses  mentioned in the  thesis of M. Bayeul, and  which
 led to the supposition of the existence of a hernia.  It is in this layer
 also that we find the veins which return from the integuments of the
 abdomen as well as their corresponding arteries, and it is here  that
 are  seen those adipose tumors  and growths of every  description
 which I have mentioned while speaking of hernia in general.  As to
 the  saphena vein,  though  situated in  this intermediary  layer,  it is
 always crowded behind and  below the tumor.

                     § III.—Strangulation.

  The opening which gives passage to a crural hernia, is  so firm and
solid, and the tissues which receive and envelope it  at the thigh, op-
pose to it in general so great  a degree of resistance, that it rarely ac-
quires  any very  considerable size.  Being obliged to traverse an
orifice which is deeply  situated;  liable  to be arrested in  the canal
itself, either above, at its middle, or at its femoral orifice; or to make
its escape through a rent in Poupart's ligament, as has been seen by
M. J. Cloquet, or through an opening in Gimbernat's  ligament,  as I
have seen in the pelvis of a  woman operated upon  by M. Laugier,
the diagnosis of the existence of this hernia in persons who are fat,
and  particularly in women, in whom it is so common, is  frequently
attended with a good deal of difficulty.   It is readily perceived  that 
358
NEW ELEMENTS OF OPERATIVE SURGERY.
 the same arrangement renders the operation more laborious than that
 of inguinal  hernia.  It is moreover owing to this narrowness of the
 passages, and to their slight degree of distensibility, that this hernia
 becomes strangulated with so much facility, and that it is so difficult
 of reduction as soon as the slightest degree of constriction exists.  In
 its interior have been found the same organs as in the inguinal, to-
 gether with the same anomalies  and the same pathological altera-
 tions.  Though experience establishes that its sac, which is generally
 thinner than in oscheocele, does not usually contain but a very small
 quantity of serum, frequently a few drops only, and sometimes  even
 none at all, there  are nevertheless examples in which it has  been
 found there to the  amount  of over several ounces, that is to say, in
 great quantity, as  I have seen in supra-pubic hernia.   In a woman
 whom I operated upon in 1836 at the hospital of La Charite, the sac
 contained nearly two tumblers of serum.  M. A. Berard (L'Experi-
 ence, t. III., p. 216) has  since noticed a  similar fact in a lady who
 died from hernia of the fallopian tube.  It is moreover in the vicinity
 of crural hernia that I have most  frequently met with those adipose
 layers and productions which have been described  farther back.

                       § IV.—Operation.

  Kelotomy at the fold of the groin requires still greater precautions
 than that at the scrotum;  in the first place, because we arrive more
 suddenly down on the sac when there is no complication, and because
 in the contrary case  we have to  distinguish all the  diseases which
 may be developed in this  region, from  hernia properly  so called ;
 again, because the sac being very thin  and frequently confounded at
 its external surface with the cellular tissue, is readily opened before
 we are aware of it, and because from its containing scarcely any se-
 rum we may easily wound the  intestine; in the last place, because
 we have to act at a great depth and to divide  the  stricture through
 parts which are almost invariably surrounded with vessels.
  A. The division of the integuments should, or almost always may,
'be made in the direction at the same  time of the inguinal groove and
 the great diameter of the  tumor.  A simple incision  in general an-
 swers ;  nevertheless if the  hernia should  be of large size, and  diffi-
 culty should exist in laying bare its neck, there  would  be  no objec-
 tion to our transforming this first division after the manner of Boyer,
 into a T incision, by directing the bistoury subsequently upon its up-
 per or lower lip, according as there may exist  a necessity of laying
 bare the inner or the outer side of the canal. Moreover there would
 be  no reason why we  should  in all cases make a T incision the
 vertical branch of which should be directed upwards, as  is recom-
 mended by M. A. Cooper, in order to run no risk  of wounding the
 internal saphena vein.  The crescentiform incision would  be  prefer-
 able.  The  crucial incision moreover, as recommended by Pelletan,
 and which Dupuytren frequently used, can be but seldom required.'
 If however we should decide upon having recourse to it, the appre-
 hensions of the English surgeon in regard to the  saphena, need not
 in any manner deter us, for this vein is always placed below and be-
 hind the hernia. 
CRURAL HERNIA.
359
  B. After the opening of the sac it is, as Boyer remarks, as rare to
find ourselves enabled toreduce the organs without debridement, as
it is  common to see the intestine excoriated, ulcerated, or even per-
forated  in the portion which sustains the strangulation.  The con-
striction being in general caused by the cutting border of the falciform
or cribiform fold of the fascia lata, it is the circle of the intestine em-
braced by these two parts which we must first examine.  The ulce-
ration existed in this place in the patient operated upon in my presence
by M. Wessely, also in  the women whom I have operated upon
myself,  and  upon  several of the individuals operated upon  by MM.
Roux, Boyer and Lawrence, as I have already mentioned.
  C. It was  in consequence of the dangers of debridement in crural
hernia,  especially, that dilatation was suggested.  Upon the outside
it was said you will have the epigastric  artery, above the spermatic
cord, and on the inside, you will wound  the obturator, if it originates
from the epigastric.  Happily these dangers are infinitely less in prac-
tice  than in theory.   Sharp divided the stricture upwards  and  out-
wards,  and though he operated upon a great number of persons, we
do not find that he wounded the supra-pubic artery, the ligature upon    »
which,  moreover, he considered  a very easy matter.   Pott divided
upwards, and the spermatic  cord does not appear  to have  been
wounded by him.  From the time of Gimbernat most surgeons
divide  upon  the inside,  and  there  is nothing to  show that by this
mode the infra-pubic branch  has  been  frequently wounded.  It  is
sufficient, however, that the thing is possible, to induce the practitioner
not to neglect the  means by which the wounding of this artery may
be avoided with the greatest certainty.  M.  Jacquier d'Ervy  and
M. Pigeottes de Troyes (communicated  by M. Jacquier, 21st March,
1839,) have each lost a patient in consequence of wounding this  ves-
sel.  The process  of Sharp is evidently the most objectionable of all.
Dupuytren, who appears to have reproduced it, and to  have  followed
it in  his practice for a long time, has modified it in such manner that
it no longer possesses the same dangers  in such cases.  It was upon
the external border of the opening at which the saphena vein enters,
that  is,  at the opening of the  fascia lata, that this surgeon directed
the cutting  edge  of his convex  bistoury, in  such  manner that he
divided the tissues from before backwards, or from below upwards,
and in this manner destroyed the strangulation before arriving at the
place in which the artery to be avoided  is situated.
  I.  The debridement upwards and slightly inwards  is unattended
with any danger in women when there is no anomaly in the vessels.
In man, on the contrary, it might expose to the  risk  of wounding the
spermatic vessels.   Arnault states that  he was witness to an opera-
tion, in other respects well performed,  but from which the patient
nevertheless  died in consequence of a hemorrhage from the spermatic
artery.  Scarpa especially endeavored to demonstrate that it is almost
impossible to divide in this direction without meeting  with  the acci-
dent pointed  out  by Arnault.   Experiments undertaken by this last
mentioned surgeon, in presence of  Bassuel  and  Boudon, would go to
show, in fact, that by dividing Poupart's ligament from below up-
wards to the extent of two or three lines, we almost inevitably wound
the spermatic artery.  Accident or other circumstances have misled 
360          NEW ELEMENTS OF OPERATIVE  SURGERY.
these surgeons.  In the first place, it is incorrect to maintain that the
spermatic cord  lies immediately upon the bottom of the groove of
Poupart's ligament.  Some fleshy fibres and cellular tissue, occasion-
ally in considerable quantity, usually separate them.   It  is not under
the border of the internal oblique muscle that the cord passes, but in
fact between its fibres.  Moreover, this ligament, at the inner half of
the ring, has a height of four to five lines.
   II.  Outwardly we could divide it entirely, which is  never indis-
pensable, without incurring any risk. Though when there was given
from six or  eight to ten lines  to  the  debridement, the danger which
gave so much alarm to Arnault,  Scarpa and other modern surgeons,
could  not be denied, at the  present day, when we generally  give
it  only from two to  three  lines, such  fears have, in fact, but very
little foundation.   The case related by M.  Lawrence would furnish,
moreover, an additional proof of this, for, notwithstanding the com-
plete division of the external border of the  obliquus externus muscle
in the case which he speaks of, the cord was not touched.  Moreover,
can it be that an artery of such little importance as the one which
comes from the epigastric to the scrotum, or the spermatic artery itself,
Can be of a nature  to give rise to so serious a hemorrhage ? Besides, it
would be upon the outside of the peritoneum that such division would
be made, and upon this supposition we cannot perceive how there could
be any difficulty in obliterating it, either by a suture, ligature, tam-
poning, or compression.  Finally, was not Arnault himself deceived ?
and was it in fact  the hemorrhage which caused the death of the in-
dividual in the case which he mentions ?  Were there not in this  case
some  particular circumstances which he had omitted to mention ?
   III.  Gimbernat,  whose labors  had already  been made known by
M. Parcet e Venuale^s  in 1807,  having studied with more attention
than his predecessors the anatomical arrangement of  these passages,
Considered that we might avoid the danger of the process of Sharp,
and the lesion of the cord, by dividing the  stricture  inwardly.   His
object  being to separate, by means of the curved or straight bistoury,
the triangular expansion which has  received  his name,  from the
lower border of Poupart's ligament, he directs his instrument to the
upper  part of the  inner semi-circumference of the ring, and after-
wards carries it  obliquely inwards and downwards, as if for the  pur-
pose of reaching the pubis by following  the  course of the external
border of the inguinal canal.  In  this manner, he says, we are certain
to avoid the epigastric artery and the spermatic vessels.  Scarpa
and the  moderns  assert that we might also, in the same  manner
avoid the obturator when it comes from the supra-pubic artery, pro-
vided the incision followed in some respects the  same turn which the
vessel  makes ; but  to obtain this advantage it would be necessary not
to divide the ligament  of Gimbernat transversely upon its middle
portion, and still less to do so obliquely, from  below upwards, while
grazing the  body of the pubis, as a considerable  number of French
surgeons appear to have understood this direction, and as they daily
practise.  Though this  method may be  preferable, what we have
said above  of  the varieties  which  have already  been  frequently
noticed in the epigastric and obturator vessels, proves  that it does
not completely secure us from  hemorrhage.   We should even incur 
CRURAL HERNIA.
3tfl
considerable risk of this result, if the epigastric artery, or one of the
epigastrics when there were two of them, should be found situated
upon the inside of the neck of the sac, and also in the event where a
large sized branch proceeding from the internal iliac vein or from the
hypogastric vein, should also ascend  upon the inside of the ring, in
the manner pointed out by M. Manec in his  thesis, and as M. Me-
niere also states he has seen it.
   IV.  In this respect the  debridement upwards is perhaps the one
which would  protect  us, with  most certainty, from "the  danger of
wounding the arteries, especially if, as is recommended by M. Ma-
nec, the bistoury should be directed  to the upper angle of the ring,
in order to make a partial division of Poupart's ligament perpendicu-
larly to its axis.  Some persons, moreover, object to the debridement
inwards from  its exposing us to the risk  of wounding the womb and
the intestines in pregnant women, or the bladder when it is distended
with urine.   Hey, who cites a case of this last description  and who
had never wounded the epigastric artery nor never seen it wounded,
concludes therefore, notwithstanding the  remarks of A. Cooper, that
it is generally better to incise the ring upwards and outwards, in the
manner practised  by Sharp; but it is evident  that a careful surgeon
may always avoid, without any difficulty, both the bladder and the
uterus, so that did not the  process of Gimbernat involve other dan-
gers the objections of  the skilful practitioner of Leeds would be of
very little value.   The circumflex artery arising, by some anomaly,
from  the epigastric or vice versa, in such manner as to pass in front
of the hernia, is the only one which we are  utterly unable to escape
wounding, unless  we should have had it in our power to recognize it
while laying bare the sac ;  fortunately, as its division would be made
very near the outer surface, it could easily be seized and tied.
   V. Process of the Author.—In conclusion, the most certain method,
in these  cases, of effecting the  debridement  without danger, is to
incise successively, on several points, the sharp border of the crural
canal, to the extent only of one to two lines for each division.  The
anatomical arrangement of this passage,  and the operations which I
have already performed, induce  me  to believe that the constriction
there is always caused by the free border of  the falciform process,
the concavity of Gimbernat's ligament, or the neck of the sac, and
scarcely ever by the  upper ring, properly so  called;  so that  it will
almost always be found that we can effect the  debridement required,
by incising the lower opening of this passage upon one or  several
points, and without the necessity of directing the bistoury into  the ab-
domen.   Having almost constantly divided the stricture in this manner
since 1831, I have been enabled to satisfy myself that it is the most
certain process.  The blunt-pointed bistoury  directed from  within
outwards or transversely, and from below upwards, upon the fibrous
ring, would have to divide  the entire base of the falciform fold of the
aponeurosis and the whole thickness of Poupart's ligament, before
running any risk of wounding the epigastric vessels.  It is the only
kind of incision which has nothing to  fear from anomalies  in the
course of the arteries, and which enables us, without any difficulty,
to obtain a debridement of from six lines to an  inch in  extent.  If
this opinion is not adopted, the debridement will have to be performed
   vol. in.                     46 
362
NEW ELEMENTS OF  OPERATIVE SURGERY.
 according to the rules laid down by the surgeon of Madrid, or if we
 are no longer disturbed by the apprehension of wounding the sper-
 matic cord, it may be made from below upwards.
   D. An operation of kelotomy performed at La Charite in the time
 of Boyer, proves, nevertheless, that the debridement inwards may be
 followed  by hemorrhage.   Arterial blood flowed in large quantity
 through the wound, and an assistant was obliged to apply his finger-
 to the bottom of the ring in order to make compression from  behind
 forwards.  Boyer immediately had recourse to the introduction of a
 small linen sac passed  as far as into the iliac fossa, and which being
 afterwards filled with  lint  served as a substitute for the finger of the
 assistant.   This application was not removed  until at the expiration
 of five days.  The hemorrhage did not reappear, and the patient was
 completely restored.   To assert what  artery had been divided would
 in my opinion be a difficult  thing.   Was  it the obturator  coming
 from the epigastric ?   It must then  be admitted that it had  passed
 above the neck of the hernia.   Was it the epigastric or an abnormal
 epigastric,  as in  the case of Lauth ?   Was  it  not  rather a small
 branch which is usually sent off by the supra-pubic artery behind the
 symphysis, and  which, from having been more  developed  than
usual, had given rise to this accident ?  On  this point we can form
conjectures only
  E. The relations of the vessels with the neck of the sac  would
render a mistake so dangerous, if, as  has been seen by Richter and
A. Cooper, an inguinal could be mistaken  for a crural hernia, and
vice versa, that the surgeon should never lose sight of them. A crural
hernia pushed back in front of the inguinal canal by ancient cicatrices
in the  fold of the groin, as has been seen  by M. Boulu, might  so
 easily deceive on this  subject, that a debridement outwards as  in
 bubonocele would expose the  epigastric  artery.   M.  Roux, who
 divides the stricture like Gimbernat,  considered  himself very fortu-
nate in ascertaining  by dissection that an inguinal, which  he had
 mistaken and operated  upon for a crural hernia, had protruded upon
 the inside of the artery, and was in fact direct or internal.  Had not
 Pelletan in a similar case discovered his error  upon arriving  at the
 viscera, it is quite probable that chance would not have  served him
 so good  a turn and  that the epigastric artery would have been
 exposed to the greatest danger.
  F. Two other methods of debridement for crural hernia have been
 proposed by MM. Else, Colliex and A. Cooper ; I have already made
 some mention of them while speaking of hernia in general, and of in-
 guinal hernia in particular.  In the first of these methods the surgeon
 incises the aponeurosis of the  external oblique above  and  in the
 direction of Poupart's  ligament, separates the cord which he  pushes
 aside inwards and upwards, penetrates down  to the peritoneum,
 glides  from behind forwards, or from the  interior to the exterior a
 curved sound between the neck of the sac  and the ring, and then
 divides the stricture without danger and to as great an extent as he
 desires.  In the second method  it is also  necessary to  divide the
 aponeurosis ; but the debridement is effected from the exterior to the
 interior, though without opening the  sac.  These  two processes,
 which were tested in  several instances in the hospitals of London, 
CRURAL HERNIA.
363
before M. Colliex had  spoken of them, are attended with too many
inconveniences to be generally adopted or to make it necessary for
me to describe or to refute them in detail.  To make the debridement
directly  backwards,  as is recommended by M. Verpillat, and who
advises that we should incise the pelvi-crural band, would  answer
only in certain  cases,  and would moreover be attended with too
many difficulties to be  adopted in  practice.
   [Femoral Hernia with complication of foreign bodies and worms,
in the practice of Dr. Proudfoot and  Professor Mott.—A remark-
able case  of femoral hernia,  complicated with foreign substances
occurred to Lawrence Proudfoot, M. D., of this city, (private com-
munication from the author.)   This  surgeon thus describes it:
   " On the 24th March, 1842, at 5  P. M., I was called to visit a maiden
lady, aged 72 years, whom I found much debilitated, and laboring un-
der symptoms of strangulated hernia, with hiccup and stercoraceous
vomiting ;  upon inquiry and examination I found a tumor of the size
of a hen's  egg, covering Poupart's ligament on the left side, and  a
general  tumefaction of the abdomen.   By the  application of pound-
ed ice the  tumor was  somewhat  diminished in size, and I employed
the taxis as long as a reasonable  hope and the safety of my patient
admitted, but the extreme tenderness of the parts, the prostrate con-
dition of the patient, and a continuance of those distressing symptoms
attendant upon a strangulated hernia induced me to  delay the means
for her relief no longer, and at 10 P. M. the  same evening I pro-
ceeded with the operation.  The intestine  had been  strangulated
about eighteen hours.   There was an unusual quantity of fluid in the
sac, for a femoral hernia; the intestine was in a good state to return,
and the  adhesions were slight and  easily detached. I  divided the
stricture, and after gently drawing down the intestine, returned it and
closed the wound with a suture and  adhesive straps, applying a firm
compress and a T bandage.
  " In two  hours the  bowels were freely moved, and all unpleasant
symptoms disappeared.  On the fourth day I dressed the wound and
it had all the appearance of doing  well.  On the sixth day, a profuse
discharge of healthy pus  took place,  and at least  a pint was  dis-
charged  in twelve hours, which  continued for three or four days,
gradually diminishing.   On the'twelfth day after the operation the
patient complained of a sensation in the wound  as  of the fluttering
of a bird, and on removing the  dressings, the poultice which  had
been applied the night previous  was  tinged with  a bilious  yellow
color, and flatus escaped from the  wound, which was followed in the
course of the night by a faecal discharge.
  " On the  eighteenth day after the operation, on dressing the wound
I  discovered a black  projecting  point, and with a dressing  forceps
removed  a  piece of a sewing needle  one inch and a quarter long.
  " An artificial  anus was the result, and a considerable portion of
the contents of the bowels  daily escaped  from the opening, over
which  firm pressure was  constantly made, and enemata daily used
to solicit  discharges by the natural outlet.
  " The artificial opening continued  about three months, at the expi-
ration of which time it was permanently healed,  and the discharges
took their natural course. 
364
NEW ELEMENTS OF OPERATIVE SURGERY.
   **The calibre of the intestine at the aperture was much diminished,
 and there was at  times a considerable  collection of faecal matter in
 the colon immediately above it, but by gentle pressure and manipu-
 lating with the fingers the contents passed through the stricture, and
 the bowels were relieved.
   " The needle is  believed to have been in the system twenty years,
 as at  that time her family  remembered of her having swallowed
 the two parts of a broken needle ; the  piece taken out of the wound
 was the pointed extremity, and about two-thirds of the entire length.
   " She had very frequently and  for a long  period  complained of
 pain in her left side, but sought no other relief than was afforded by
 grasping the side  and applying  pressure.  There was no swelling
 or attendant symptom whereby an abscess could be detected or sus-
 pected, and I know not how to account for the immense discharge,
 other than being the contents of a psoas abscess evacuated through
 the agency of  the  needle."          *
  Dr. Proudfoot refers to the case of Dr. Mott, as follows:
  " I may here make mention of  a case which occurred in the prac-
tice of my  preceptor,  Dr. Valentine Mott, while I was his  private
pupil, and in which operation I had the great privilege of assisting.
I believe the case has not been published, and as it may be consid-
ered as bearing some relation to the above,  I will take the liberty of
alluding to  it.   The patient was a lady of middle age and of robust
constitution, who had a femoral hernia.   The operation was perform-
ed by Dr. Mott, in his  accustomed cautious manner, and with great
elegance.   The wound was closed by sutures, adhesive straps, com-
press and bandage, and on dressing it on the fifth day, a worm about
four  inches  long, of the species  of the lumbrici, was discovered
coiled up below the sutures and between the lips of the wound.  The
intestine was in a  good state to  return, there was not the slightest
appearance of sphacelus or  ulceration,  and  if it had  been acciden-
tally wounded  by  the knife, would have been immediately discov-
ered by the bowel becoming collapsed previous  to  its  being re-
turned.
  " The records of cases furnish examples where worms of this spe-
cies get into the cavity of the peritoneum,  or insinuate themselves
into the bladder or vagina: the wound healed very kindly and the
patient had not an  unfavorable symptom.
  New  York,  July 21th, 1846.                           L.  P."

               Article III.—Umbilical Hernia.

                   §  I.—Anatomical Remarks.

  The umbilicus during life  presents itself in  its relations  to hernia,
under  two very different conditions.   Before birth it  is a slightly
resisting ring, which is  traversed at the same  time by  the three
umbilical vessels  and  that prolongation from the bladder,  known
under the name of the urachus.
  A. As soon as  the infant is separated from its mother the parts
contained in this ring contract and consolidate, and thus cease to fill
it up entirely;  hence it is through this part that the intestines, during 
UMBILICAL HERNIA.
365
the first months of life, have a constant tendency to make their escape.
Subsequently the ring itself, in  its turn, contracts, closes up, and be-
comes attached upon the fibrous nucleus formed by the remains of the
vessels ; in such manner that the whole finally presents itself under the
aspect of a very dense inodular  cicatrix, so that in adults umbilical
hernias no longer take place at  the ring, properly so called, as in
infancy, but  by protruding through the aponeurotic fibres at the dis-
tance of some lines upon the outside of it.
  B.  We are to understand ourselves, however, when it is said that
umbilical  hernias  do  not take place through the ring in adults.   If
we reserve the name  of exomphale to the hernia alone which pushes
in front of it the cicatrix by dispersing or destroying it as it were, it
is true that it is to be  met with only in infants; because, in fact, it is
not possible, excepting in so far as the various branches of the ompha-
lo-placental cord have not yet  been enabled to become consolidated
together and transformed into a fibrous nucleus.   But if it be con-
ceded that there is an umbilical hernia in every case where an organ
has escaped through the ring, which during foetal life was filled up
by the expansion of the vessels, there can be no  doubt that such her-
nia is possible, and that it has been observed at  every period of life.
If in this case the cicatrix is usually deviated either to one or the other
side of the tumor, this is owing to its always being  a little less adhe-
rent upon some points of its circumference than upon others.  Scarpa,
however, relates that in one of his patients the sac was divided into
several compartments  by  the  ligaments of the umbilical nucleus.
This  fact,  which I was the first to call attention to among us. has
been  since confirmed by the researches of  M. Despres (Arch. Gin.
de Mid.. 2e ser.,  t. IV., p. 275,) and M. Cruveilhier.  Moreover, as
in this place there is no circle or  canal naturally open, it is very na-
tural  that hernias should take  place almost as frequently through a
rent in the aponeurosis or linea alba as through the umbilicus itself;
so that Monteggia, who was one of the first to declare that hernias
in this region might take place external to the  ring,  was wrong only
in stating that to be constant which is only very frequent.
  C.  However this may be, the  viscera at this part never protrude
except through  a simple ring.   There is  no umbilical canal,  and
scarcely an instance is  known in which the arteries have preserved
their calibre up to adult age. According to the assertions of Haller,
Boerhaave, and some others, the case is different with the vein, whose
permeability, however,  is so rare an occurrence that it need not dis-
turb us during the operation.
  D.  As it is through  a simple circular opening, and not along the
track of a canal, that  the viscera make their  escape, umbilical her-
nia, unlike inguinal or crural, has  no fibrous or serous sheath to stran-
gulate it at a certain variable distance from its root.  The peritoneal
layer  which is found here, does not possess, or but very imperfectly,
the characters that belong  to  it  in hernias of the upper part  of the
thigh,  and it is to exomphale  that the remarks I have made on the
subject of the absence  of the sac while treating of the operation in
general, are rigorously applicable.  It is this which Lassus states that
he found destitute in one case of envelope, or surrounded by such as
were so attenuated, that he opened into the intestine, which had passed 
366
NEW ELEMENTS OF  OPERATIVE SURGERY.
 through a rent in the epiploon.  Upon the strength of a fact furnished
 by M. Pierquin, (Journ. de Prog., t. XIV., p. 253,) this  author also
 maintains that umbilical hernias are destitute of a sac.   The external
 surface  of  this  membrane,  in  fact, is  so  closely united with  the
 surrounding tissues, that it  is impossible to separate it from  them.
 It  was  nothing else,  in  tiuth, but a  portion of the  peritoneum
 which originally lined that part of the  ring, which the organs have
 pushed  before them in forming  the hernia.  Having become  en-
 larged by simple distension, in the manner of a cell of lamellar tissue,
 which is dilated in order to form a cyst, and not  by the progression
 of,  or traction upon, the abdominal peritoneum,  properly so called,
 this  sac  cannot, as  in the groin, be distinguished from the other tis-
 sues.
  E. A peculiarity no less important in practice is this, that in umbi-
 lical hernia  the sac scarcely ever contains  any serum, from  whence
 it happens that it is almost constantly  found in  immediate  contact
 with the  viscera.  I would remark,  however, that this law has been
 laid  down in too peremptory a manner.  In a woman whom I ope-
 rated upon  for strangulated exomphale, there  were  more than  six
ounces of reddish colored serosity in the interior of the  hernial  en-
velopes,  and about  three  ounces were  discharged in another case
which was operated upon at Tours, in 1818, by Pipelet, and to which
I was a witness.
  F.  The organs which maybe displaced in order to form an umbil-
ical hernia, are, according to the order of their frequency, the epiploon,
transverse colon, small intestine, stomach, caecum, sigmoid flexure of the
colon, liver,  and duodenum, and even the pancreas.  These different
organs are  sometimes  found in so great a number,  and under the
 form of a mass so considerable, that their containing pouch becomes
extremely attenuated, and to so great a degree even as ultimately to
burst, as  took place  in  the patient mentioned by Boyer, and  whose
 life could not be saved by the operation.   In more than one instance
they have been seen, in the foetus especially, totally deprived of enve-
lopes or only covered  by an  exceedingly attenuated  membrane.
 Mery and Balzac have cited examples of this kind.   I myself saw
one at Tours in 1819, in the practice of Mignot, andM. Dupuy show-
 ed me another in 1835.
  G.  It sometimes happens, but not always as some facts at first  in-
 duced me to think, that the digestive  tube is  sometimes lodged du-
 ring the first periods of foetal life,  in the root of the umbilical cord.
 Now if the intestines do not return, or only partially return before
 the end of pregnancy, the  infant is  born with an exomphale.  The
 viscera in such cases would be enveloped only by the attenuated  tu-
 nics  of the omphalo-placental cord, and it may  be easily conceived
 that  distension might rupture this feeble partition in such manner as
 to expose the hernia completely naked.   The  same thing might also
 happen in the first hours or during the first days of birth.  Under
 this point of view therefore, there is an  essential difference to  be
 made between umbilical hernia in the foetus, that of the first  periods
 of extra-uterine life, and that of adult age.  In the first, it is the na-
 tural tunics  of the cord which  form the sac  and  the envelopes ; in
the second, the cicatrix having had time to form, the organs  in pro- 
UMBILICAL HERNIA.
367
 truding have become capped (se coiffer) with the peritoneum, integ-
 uments and intermediate cellular tissue ; in the third, the sac, obliged
 to pass between the vessels or upon  the  side of the  common knot
 which unites them, is moreover, in the majority of cases, compelled to
 lacerate the interior of the ring  or  the  neighborhood of its circum-
 ference, in order to work out a passage for itself, and  to  arrive ulti-
 mately under the skin in gradually distending the corresponding per-
 itoneum.  An umbilical hernia, though very large, having been kept
 reduced, disappeared  spontaneously in a new-born  infant mentioned
 by M. Requin, (Gaz. Med., 1832, p.  640.)  In an infant which I saw in
 1837, in company with M. Delafolie, it had diminished to the extent
 of  four-fifths of its  dimensions, after a compression continued for two
 months.  A ligature applied incautiously upon the  root of  the cord,
 effected its strangulation in the cases related  by M. Poussin, (Journ.
 de  Med. et Chir., t. I. et II.,) Burret, (These, No. 162, Paris, 1833,)
 and Brun, (Ibid., No. 238, Paris, 1834.)
   H.  Frequently also the hernia  takes place, in fact, at  some dis-
 tance from the umbilicus or in its periphery.   So long as it is distant
 only one or two lines from this  cicatrix, its texture, and the relative
 arrangement of its parts have nothing special;  but if it is ever  so
 slight  a distance  beyond  this,  its  sac and  cellular  lining present
 themselves  under  different characters.   The  peritoneum, which is
 then more movable and less adherent, admits of being drawn upon
 and displaced without  difficulty,  and the hernia  is found  in this
 manner to be furnished with an unequivocal  sac.   From the fascia
propria having partially  regained  its laxity and thickness, the sac
 may be distinguished from the external tissues, while fatty matter and
 serum sometimes accumulate within its  lamellae.  Frequently also
 adipose tumors or hernias have been found  to  develope themselves
 around the umbilicus. Fardeau mentions an instance of one which was
 prolonged as  far as the interval between the two layers of the sus-
 pensory ligament of the liver.  M.  Bigot, M. Ollivier d'Angers, and
 Beclard, as well as Heister, Petsch, Morgagni,  Klinkosch,  Pelletan,
 Scarpa,  M. Lawrence, M. Cruveilhier, and  M. B6rard, have also
met with them, and I  myself have  frequently noticed others which
had their root in  the infra-peritoneal layer.  I  have  dissected one
also which was prolonged into  the falciform  fold  of the  umbilical
vein.  It was probably above this cicatrix, that the hernia mentioned
by  M.  Cloquet, which  had pushed  before it, while  un-lining it, the
hepatic ligament to  procure in this manner a sac, made its escape.

                        §  II.—Operation.

  The operation for umbilical hernia is considered to be  exceedingly
dangerous, and in reality appears to be more so than that for ingui-
nal  or  crural  hernia.  If we admit the fact, it  is owing perhaps to
our operating  near  the stomach  or  diaphragm,  to the circumstance
that the organs  contained in  the tumor  are in immediate relation
with the principal viscus of digestion, or because we  do not decide
upon the employment of the cutting  instrument until at too advanced
a period of the disease.  Another reason would also be  found in the
fact that after the operation it is impossible to place the wound in a 
368
NEW ELEMENTS OF  OPERATIVE SURGERY.
 depending position, and that the pus and other extraneous fluids are
 thus compelled to fall back into the peritoneal cavity.
   A. If the tumor is of moderate size it may be laid bare by a simple
 incision parallel to the direction of the linea alba.  In  the contrary
 case there is no reason, whatever Scarpa may say on the subject,
 why we may not  have recourse  to the T, or  even the crucial in-
 cision, but I prefer the one in the form of a crescent.  In ordinary
 cases we give sufficient length to this incision to go a slight distance
 beyond the hernia at its two extremities.   In this hernia the integu-
 ments are, in general, too  much stretched, and would have too much
 difficulty in puckering up to require us to take the precaution to raise
 them before dividing them. We incise them, therefore, from without
 inwards in the same way as for laying bare an artery.  The subjacent
 layers are also to  be divided in the same  manner, that  is to say, by
 drawing the bistoury over them with all the caution requisite.
  B. As it is not possible to isolate the sac, we  could not lay it bare
 without  difficulty  if we persisted  in dividing layer by layer, and en
 dedolant, on one point only, the  layers which  separate it  from the
 skin.  As, however, it is frequently very near the cutaneous  envelope
 and does not usually contain but a very small degree of serum, we
cannot  observe too  great degree  of precaution in  cutting  down
upon it.   Tumors  of different character may produce embarrassment
here as well as elsewhere.   In a woman whose case was communi-
cated to  the Academy, I was obliged to cut through a fibrous trilo-
bate mass as large as  the fist  before reaching the intestine, which
was found strangulated at  its pedicle.  From the moment when the
bottom of the incision presents the appearance of being  formed only
 by a very thin lamella, the instrument is to  be used  with a still
greater  degree of caution; as soon as the  layer which we  have
divided is found to be separated from the parts which it covers by the
 slightest interval, the grooved sound is then to be glided underneath
 it, for we have  now probably arrived in the  sac.  There will  now
 no longer be any doubt upon this subject should  the slightest quantity
 of liquid make  its escape, or if, as has been observed  in  most in-
 stances, some adipose pelotons show a disposition to protrude through
 the opening.  Once arrived in the interior  of the hernial sac, the
 bistoury, guided by the forefinger,  if we make use of the blunt-pointed
 bistoury, or by the grooved sound in the contrary case,  immediately
 enlarges the first orifice and makes a free division of all the envel-
 opes of the tumor.
  C. It is in umbilical hemia, especially, that  we meet with the
 epiploon, and in such  manner as to form  here, in some instances, a
 mass of considerable dimensions.   We must not,  however,  allow
 ourselves to  be imposed upon  by appearances.  We almost always
 find below it a noose of the intestine, which  it envelopes in forming
 for it a sort  of second sac.   For the same reason we find in this her-
 nia, more frequently than  in others, that the intestine has lacerated
 its epiploic investment, passed through it and become strangulated in
 the ring itself which is the source of this hernia, and thus  placed itself
 in immediate contact with the  surface of the sac, properly so called.
  D. After the opening of the  sac therefore, the first thing  to be at-
 tended  to is to identify the arrangement  of the displaced organs. 
UMBILICAL HERNIA.
369
We therefore search with the finger for some portion of the epiploon
which is not adherent, in order to raise it up and to  unfold and
spread it out upon one of the borders of the wound.  The intestine,
if there is any of it  in the tumor, is then seen  below it.  In those
cases in which this  simple displacement of the  parts will allow of
their  reduction, we  must immediately proceed  to  this step.  Hey,
and since him almost all operators, have strenuously insisted  that the
reduction should commence with the intestine, and not with the epip-
loon  as recommended  by Pott.   For the intestine being  the last
which has come out, and  being situated at  the  greatest  depth, and,
in general, more easily pushed back, is the part,  in fact, which ought
to be first reduced.  Nevertheless if a contrary  arrangement should
be met with, and  the return of the epiploon be attended with less
difficulty  than  that  of the intestine, I can  see  no reason why we
should persist in following the rule laid down by Hey.
   E. When the intestine is gangrened, a circumstance which must
be rarely met with, inasmuch as it is known, that mortification is in-
finitely more tardy in its development in hernias of the large intestine,
and  in entero-epiploceles, and especially in hernias purely  epiploic,
than in enterocele, we ought  to  recollect  that  stercoral fistulas, or
an artificial anus at the umbilicus can scarcely ever  be  cured.  This,
as Scarpa has clearly established, is owing to the fact, that there is no
membranous infundibulum formed behind the umbilical circle and at
the expense of  the sac.   How, in  fact, could such  a formation take
place, since the serous surface  of the hernial pouch closely adheres
to it,  and is wholly formed and developed  out of the umbilicus, and
has not been borrowed from the interior peritoneum, as it is  in ingui-
nal and  crural hernia ?   Gangrene or any perforation whatever,
therefore, of the intestine  appears to require, under such circumstan-
ces, that we should have  recourse immediately to invagination or to
the suture, and  not attempt to establish  an artificial anus.  I would
remark, however, that in the operation performed by Pipelet, and
which I  have mentioned farther  back, a gangrenous eschar of the
intestine was removed, and that a fistula was established, which being
left to itself, ultimately closed  up and cicatrized  perfectly.   It was,
moreover,  in a case of umbilical hernia  that  M.  Chemery-Have
successfully performed  invagination, and the remarkable operation
related by Scarpa, who quoted  it from the Ancient Journal of Me-
dicine.
   F.  The  debridement,  when  necessary, is so easy  and  attended
with  so little danger, that we scarcely ever dispense  with  it.  We
may  make it almost upon this or that point indifferently.  Cases
might happen in which  it would  be possible to  wound the liver, the
umbilical vein or arteries, and even the  urachus: but this could not
happen, so to speak, unless we did  it purposely, or unless such ano-
malies existed as  are too unusual  in such cases  to  render them the
subject of apprehension.   We must  not, however, forget the abnor-
mal veins mentioned  by  MM. Manec and Meniere, or those that  I
have  myself mentioned.   Though there may not be any more per-
ceptible advantage in incising  the umbilical  ring below than in any
other direction, I  see no  inconvenience in  following  the advice of
authors who recommend for greater security, to direct  the incision
  vol.  in.                      47 
370
NEW ELEMENTS OF  OPERATIVE SCRGERY.
 upwards and to the left.   The danger from incising largely of weak-
 ening too much the walls of the belly, and exposing the patient to an
 almost certain return of the disease, might, it seems to me, be easily
 avoided, if in place of making a single incision, and giving it  half an
 inch in depth, we  should make three or  four  of them at different
 points, and of one or two lines only in extent, as was done by me in
 the patient whom I operated  upon with M. Gresely, and  in  several
 other instances;  if. in a  word, we should adopt the multiple  de-
 bridement in  umbilical hernia, in the same manner as in those which
 I have already spoken of.
   G. Although  there may not  be  in exomphale, properly so  called,
 any strangulation by the neck of the sac, and that the ring which pro-
 duces the constriction is  almost  constantly smoothly rounded, pru-
 dence, nevertheless, dictates that we should examine before proceed-
 ing to the reduction, what may be the condition of that portion of the
 intestine which has been  strangulated.   If we should  decide upon
operating without laying bare the  whole tumor, after the method of
 Franco, Rousset or Pigray, we should particularly recollect that the
ring is scarcely ever distinct from  the neck of the  sac, and that unless
 we combine the process of Bell with this  method, as M. Raphel ad-
vises, we should not succeed in destroying  the strangulation without
penetrating at the same time into  the interior of the sac.  This pro-
cess,  therefore,  is still less adapted to the umbilicus  than to  any
other region,  notwithstanding  Scarpa recommends it with a  degree
of complaisance,  and  that  M. A.  Cooper had recourse to it success-
 full}7 in two instances under such circumstances.
  H. Immediate reunion might be  attempted with more advantage
and facility after kelotomy at the umbilicus than in hernias at the
groin.  The sac formed to some extent of a single layer, has less ten-
 dency to roll  up on itself, and is much more inclined to readapt itself
 to the points which it primitively occupied.   I would not venture how-
 ever to recommend it, because in my view the radical  cure after the
 operation is so much the more probable in proportion as the method
 of secondary intention is more completely carried into execution.
 Moreover, this is a part of  the body where the organs stand most in
 need of being supported by a moderate compression after they have
 been returned  into the belly, and  this  without doubt because the
 opening which had given passage  to them  is usually very large, and
 especially because it forms a ring  or perfect circle, which traverses
 perpendicularly the abdominal enclosure.

          Article IV.—Ventral  and other  Hernias.

                              §  I.

   Hernias at the linea alba, whether above or below the umbilicus,
 differ too little from those which I have  just examined to make it
 necessary for me to enter into  a special description of them.  Should
 they become strangulated, moreover, a  circumstance which has
 scarcely  ever  been heard of,  the  operation in  these cases  would
 have nothing special.   The same  must be said  of the hernia  at  the
 flank, or lumbar hernia, mentioned by J L. Petit, seen in one instance 
                  VENTRAL and other hernias.               371

by MM. Cloquet and Cayol in a man 75 years of age, in another in-
stance by Lassus in a man who had one on each side, and also by
Pelletan in a woman who had her belly at the same time covered over
with  ruptures.  Nor do ventral hernias, properly so called, that is
to say, those which  are formed external to  the linea alba and the
umbilicus and other natural openings of the abdomen, whether by a
simple rent in the aponeuroses and muscles, or in  consequence of a
cicatrized  wound in those parts, as has been seen by Schmucker,
Desault, Lassus, M. Richerand,  M. Anderson, and  many  others,
scarcely ever strangulate.  If their strangulation does take place, it
is at least almost always practicable to  reduce them by means of the
taxis, position, and other modes pointed out in the preceding articles.
We find however that M. Key or M. Bransby Cooper, could not suc-
ceed in reducing a strangulated ventral hernia until after having had
recourse to the operation as well as to the debridement, and that the
patient was thereby restored.   A hernia which had been  caused by
a rupture of  the umbilicus during parturition, thereby became, says
Bartholin, so enormous that the poor woman (Bartholin dans Bonet,
t. IV., p. 410) was compelled to conceal it in a bag.   Upon the sup-
position, that  all those varieties of tumors should  require kelotomy,
we should proceed in the same way as  in cases of umbilical hernia,
and they would require  no other precautions than those which would
be indicated  by the track of the epigastric, lumbar or anterior iliac
artery.  M.  Paccini, (Gaz. Med., 1833, p. 409,) in a  case in which
he was obliged to operate for strangulated hernia below the  umbili-
cus, succeeded  perfectly.  M. Goyrand, (Press. Med., t. I., p. 487,)
operating in a similar case, was no less fortunate.   A woman whom
I operated upon with  M.  Ducos,  in whom gangrene had already
taken place, and where the hernia was  situated at  four inches below
the umbilicus, also ultimately got well.   A  hernia  in  the epigastric
region, which I saw in a young girl, ulcerated and caused death, but
the child was consumptive.  The operation was completely successful
in the case of M. Castellacci, (Bull, de Fer., t. V., p. 175,)  though
the hernia was  strangulated by a cicatrix.   The  same result took
place in the patient of M. Aussandon, (These, No. 276, Paris, 1834,)
though the hernia was congenital and upon the inside  of the antero-
superior spinous process of the ilium.

                             § II.

  Obturatic Hernia,  (Hernie Obturatrice.) examples of which have
been mentioned by Arnault, father and son, Duverney, Garengeot,
Verdier, Pipelet, and  Eschenbach, and which has since been seen by
MM. A. Cooper, W. M... (Gaz. MM., 1833, p. 576) Gadermann, (Rev.
Med., 1825, t. IV., p. 128,) J. Cloquet, (These de Cone, 1831, p. 107,)
H. Cloquet, (Journ. de Corvisart, t. XXV;  Bull,  de  la Fac, t. III.,
p. 80,)  Hesselbach, Marechal,  (Journ. de Prog., t. X., p. 247,  and
t. XVI., p. 256,) and  several others, (Ibid., t.  I., p. 263,) and which is
a description  of  hernia which also appears to be sometimes liable to
strangulation, would be  somewhat  more embarrassing.  The open-
ing which gives passage to it being then transformed  into a sort of
canal, whose  pelvic orifice is formed by the pubis outside and above, 
372
NEW ELEMENTS OF  OPERATIVE SURGERY.
 and by the obturator membrane throughout the rest of its extent, is
 found to be  circumscribed  by the  tissues of the obturator muscles.
 In such cases the viscera are surrounded anteriorly by the pectineus
 muscle, behind by the  adductor  magnus, and  within  and above by
 the adductor brevis  and  adductor  longus, (moyen adducteur.)   An
 obturatic hernia being obliged to traverse these different muscles or
 to separate them apart  in order  to make  its way to  the inner and
 lower extremity of the fold of the groin, does not appear to be capa-
 ble of becoming strangulated, except at its entrance  into the obtura-
 tor canal, as in  fact was the case in the instances which have  been
 related.   It would appear that inasmuch as  the  infra-pubic artery
 must always be found upon its outer side, either above, below, or di-
 rectly outwards, the debridement would have to be made at its inner
 semicircumference.   I  am aware  that this  operation was  first at-
 tempted by Garengeot on one of his patients in the Rue de Sepul-
chre, and more  recently by  a German surgeon in a case nearly  simi-
lar.  But when we reflect upon the parts through which we should
have to divide to reach the seat of  the strangulation, and also on the
depth at which  the obturator membrane is situated, and the difficulty
of ascertaining  the  situation occupied by the vessels, and also that
the bladder or vagina might be wounded, I may be well permitted to
dispense with recommending it.  In the case of M. W. M., the stran>
gulation was upon a small portion  of the  ileum, and in that of MM.
Marechal and J.  Cloquet, it  was  an  entero-epiploic  hernia.  Gan-
grene had cribbled the sac in the case of M. Gadermann, and in an-
other  patient  we  perceive that the artery was found  on  the inside
and in front.  I have seen a fine example of this hernia in a specimen
carefully prepared by M. Demeaux, an interne of the hospitals. In
 this case, the  vessels being situated to the outside, and  in front, might
 have been more easily avoided ; but the intestine, which was a por-
 tion of the ileum,  was so entirely concealed by the  obturator exter-
 nus muscle, that it would have been impossible to have recognized
 the hernia during  life.

                             §  III.

  lschiatic, perineal, vulvar,  and  vaginal hernias  are  alike exclu-
 sively comprised within the domain of pathological surgery, properly
 so called, and have no relation to operative surgery, excepting so far
 as the taxis, position, and containing means methodically applied, con-
 stitute the principal remedy.  The eighteen instances also of perinea]
 hernia,  collected  by M.  Jacobson,  (Bull,  de  Fer.,  t.  XIV., p.  207,)
 are not  the only ones that science  possesses, and the so called vagi-
 nal hernia operated upon by M. Petrunti, (Gaz. Med., 1826, p. 424,)
 might have been  only a recto-vaginal  abscess.
   [Internal hernial sacs, of the appearance of pediculated poaches,
 filled with  ffecal  matter, have been found (Edinb. Med. and Surg.
 Jour., Oct. 1, 1845, p. 282) in  considerable numbers  on the rectum
 and  colon, and were ascertained to have been true  hernias of the
 mucous through rents of the muscular coat of the intestine.
   Diaphragmatic  Hernia.—M. Battalia  (Giornale  delle   Scienze
 Mediche, delta Soc. Medico-Chirurg. di Torino, Nos. April,  Mav 
                  VENTRAL AND OTHER HERNIAS.               373

and June, 1845; also Gaz. Med. de Paris, t. XIII., 1845, Sept. 20,
pp, 600, 601) furnishes a remarkable case of a patient aged  twenty-
nine, of robust constitution, who, owing apparently to a debauch and
violent efforts in coition  the  night before, was  seized with  all the
symptoms of strangulated hernia, as stercoral vomiting, &c, except
the absence of diffused abdominal tension, distension and pain ; the
abdomen be ng in fact rather  drawn in, or sunk or fattened in the di-
rection towards the vertebral  column;  and affected only with a slight
burning pain in the right iliac region.  This dilemma and mystery
for the diagnosis, was unravelled in a few hours by the autopsy, when
the entire stomach, the great  epiploon and a part of the transverse
colon were  found lodged  in the  thoracic cavity, having  reached
there through an oval-shaped  transverse rupture in the diaphragm to
the right of the oesophagus, and which was three and a half by two
and  a half inches in  diameter.   This had  caused the strangulation
and gastro-enteritic inflammation, the evidences of which were mani-
fest upon the displaced organs, while those of the thorax were  per-
fectly sound.  There was on the right side of the thorax a cicatrix
from  a sabre wound, received  some four years before; and  as the
edges of the rupture were somewhat hard and irregular, and as con-
siderable adhesions were found between the peritoneum and viscera,
and  principally  with  the liver, which latter was enlarged, &c, the
editor of the Gaz.  Aledicale seems  inclined to the impression that the
rupture,  contrary to  the opinion of M.  Battalia, was ancient and
from  the wound, and not recent.   The editor cites cases of  con-
genital diaphragmatic hernias, which notwithstanding, admitted of
the ultimate restoration of perfect  health, (Gaz. Med., 1843, p. 192,)
also of tolerable health  persisting  for years after such hernias from
traumatic causes, (Gaz. Med., 1843, p. 776.)
   Statistics and causes  of  hernia.—M.  Malgaigne (Lecons Clin-
iques sur les Hernies, fyc, in  1839-40,  Paris,  1841)  estimates the
whole number of ruptured persons  in France, in 1841, at sixteen hun-
dred thousand, in a population at that  time probably of about thirty-
six millions.  Of these the excess of males to females is as  four to
one.  The most numerous cases are, as is well known, among labor-
ing persons, but we cannot perceive for what reason  hernia should
prevail more among the  descendants  of one  race than  another.
Thus the Celtic or Gallo-Roman races in the central  provinces are
pronounced  most liable to hernia, while  those  of  Brittany and the
Cimbric, Norman, Germanic and Iberian races are peculiarly exempt!
M. Malgaigne also advances  an opinion diametrically opposite to the
established one, viz:  (see Op. Cit. in Arch.  Gen. de Med., 3d  ser.,
t. XII., p. 535,) that inguinal hernia, even  in women, is  more frequent
than  crural!   In the work  we  have  cited he appears  to have
furnished much  useful systematization to the subject of bandages, or
trusses for hernias, among the infinite  varieties of which he  gives  a
decided  preference  to the English bandage, or that invented by
Samson.
   At Guy's Hospital at London, Mr. P. A.  Poland furnishes 42 cases
of hernia from  September, 1841,  to December, 1842.  Of these 17
were inguinal and all in  males;  24 crural, of which 19 were in 
374
NEW ELEMENTS OF OPERATIVE  SURGERY.
females; and of 25 strangulated, 19 were operated upon, of which 9
Were cured and 10 died.
  In connection with this subject the number of cases of strangulated
hernia of all descriptions, treated at Wurtzbourg, from 1816 to 1842,
was, according to  M.  Textor, (Revue  Midico-Chir. de Paris,  Jan-
uary, 1843,) 172; of which  98 were inguinal, 71 crural, and  3 um-
bilical.  Of the whole number there were 105 cured by the taxis.  Of
56 operated upon, 32 were cured and 24 died.  Of the 71 crural, 65
were  in women and only 6 in  men.   Of the 98 inguinal, 85 were
men and only 13 women.  The  average mortality in operations for
strangulated hernia at Wurtzbourg, was 3 out of every 7. T.]
    PART  SIXTH.

ORGANS  OF GENERATION.
                        CHAPTER  I.

                  GENITAL ORGANS OF MAN.

                   Article I.—Hydrocele.

  The word hydrocele, in its literal acceptation, signifies any tumor
formed by  water; but it is only used  in  surgery for designating
aqueous tumors in the scrotum.   Hydrocele is a  common disease,
which is seen in both sexes at every period of  life, and in all coun-
tries and at any season of the year.

                   § I.—Hydrocele  in Man.

  Authors  admit  two species of hydrocele in  man: hydrocele of
the scrotum, properly so called, and  hydrocele of the spermatic cord.
Hydrocele  of the scrotum  comprises two varieties, one by infiltration
and the other by effusion.   Hydrocele by infiltration is no other than
oedema of the scrotum, and should  be  so denominated.  Hydrocele
by effusion, whether it be acute or chronic, has  its  seat in the tunica
vaginalis, or in certain accidental cysts.
  A.  Acute Hydrocele.—I understand by acute  hydrocele that which
is developed in the space  of a few days and accompanied with in-
flammatory symptoms in the scrotum.    Though common it has gen-
erally been overlooked. Any external violence  made upon the scro-
tum "may produce it.   I have  seen two instances of it after a  pro-
longed taxis, and the same result produced in  three other patients
from the operation for hernia.  It is sometimes caused by the presence
merely of a strangulated hernia. The same  may take place from any
acute inflammation whatever in the tissues  of the scrotum ; but it is
nevertheless most frequently imputable to diseases of  the testicle.   I
have met with it as a consequence in every variety of orchitis : thus, 
HYDROCELE.
375
orchitis from external causes, that from an interruption to the circu-
lation, and also urethral or blenorrhagic orchitis, in fact no variety is
entirely exempt from it.  Acute hydrocele in cases of orchitis being
the most frequent, I shall use that as  its type.  Many surgeons have
mentioned it  without apparently attaching much importance to it;
but no person, I believe, before M.  Rochoux, had  maintained that
" apart from the portion usually very small, of the tumor, which
belongs to the epididymis, the remainder is formed by a peritesticular
effusion which itself is caused by an inflammation of the tunica vagi-
nalis," in the swelling which characterizes the disease known under
the name of blenorrhagic orchitis.   I  have endeavored since the year
 1833, to ascertain out of more than  200 cases affected  with acute
orchitis, either at La Pitie, La Charite, or in private practice, what
is the actual  physical or anatomical condition of the tumor.   The
result is a conviction on my part that, in urethral  orchitis especially,
the tumefaction is almost exclusively confined at first to the epididy-
mis or vas  deferens, that it then reaches  the tunics of the scrotum
and testicle, and finally that serosity in the  tunica vaginalis also co-
operates in producing it in a great number  of cases.  I  may there-
fore add,  from these facts, that  hydrocele accompanies  about one
half the cases of acute orchitis;  but M. Rochoux, in affirming that
in this complaint the hydrocele is  almost  the whole disease and  the
engorgement  of the  tissues scarcely anything, has been most cer-
tainly deceived.   The epididymis and  the  testicle  form in fact, in
general, the third half and sometimes two-thirds, four-fifths or five-
sixths of the tumor;  the thickened tunics of the scrotum also constitute
one part, without counting that in many cases there does not exist any,
or that there is but a very small quantity of serum around the testi-
cle.   When an actual hydrocele  exists, it sometimes, though rarely,
forms as  much as one-half or two-thirds of the mass ;  ordinarily,
however, it makes up from a  sixth to a  fourth of the tumor.  Fre-
quently it is reduced to a thick [?] stratum of a line or two  in depth of
liquid around the seminal gland.   What has  deceived and what will
still continue  to  deceive  on  this point is  this, that in acute orchitis
the testicle and epididymis present a  proportionate size and consist-
ence  altogether different from the normal state.   The first of these
organs, naturally of a soft or spongy tissue, and inclosed in a fibrous
thick  shell, being now swollen and dilated as it were by the disease,
and embracing as it were the  front part of the epididymis, so readily
leads  to the supposition of a collection of liquid that it is almost im-
possible not to be sometimes deceived by it.   From the unusual ex-
pansion and hardness of the  epididymis, which  then has the form
of an egg slightly flattened on its anterior surface,  the testicle pre-
sents the appearance of a fluctuating tumor which is mistaken for the
tunica vaginalis distended by a liquid.
  Having fallen into this error myself, and having seen very expert
practitioners  also  deceived  in the same  manner, I have thought it
advisable  to suggest the  means by which we might avoid it, (Diet.
de Med., 2d edit., Art. Hydrocele.)  When there  is a hydrocele, it is
perceived that the external wall of the cyst is not obstructed by the
testicle until after we have traversed, while depressing it, a species of
void, cavity or middle portion, manifestly  less resisting than the rest. 
376
NEW ELEMENTS OF OPERATIVE  SURGERY.
 It is also perceived that this sensation is communicated upon the side*
 as well as on the front part of the tumor, hecause the tunica vagina-
 lis envelopes the epididymis down to  its root fully as much as it does
 the testicle.   A great quantity of liquid sometimes causes the dis-
 appearance of the first of these two signs, but in such cases there can
 scarcely be any room  for ambiguity.   Ancient adhesions might ob.
 scure the manifestation of the second  sign, but they  would render the
 other more clear.  If both failed, it may be said  that  there  is no
 hydrocele.  I would add, that besides  these  signs, or the transpa-
 rency, everything else  is  illusory.   Acute hydrocele, constituting
 only a superadded symptom in orchitis, does  not require any parti-
 cular treatment.   When, however, it continues  after the resolution
 of the testicular engorgement, it is advisable to attend to it.  It is to
 this affection  that we  may apply the topical  remedies which  have
 been extolled with the view of avoiding the operation for hydrocele in
 general.   I procure relief to the patient  at the  present time by means
 of puncture with  the lancet.  This puncture, which I first employed
 in order to solve the question of effusion, empties the tunica vagina*
 lis, assuages  the pain,  and  constitutes the most  powerful resolvent
 that I have met with in such cases, however acute  the inflammation
 may be.   I have now  made use  of it in more than a hundred in-
 stances, and I have never seen it produce any accidents.   MM. Serre
and Lallemand (Petra, These,  No. 65, Montpellier, 1837,) have also
 succeeded in certain cases  of chronic hydrocele by means of these
repeated punctures associated with an antisyphylitic treatment.
  B. Chronic Hydrocele.—Children are less frequently affected with
hydrocele than adults.   In these last it is so common that I have met
with thirty instances in less than a year's time at the hospital of La
 Charite.
  I.  Causes.—Irritations produced in the scrotum, cord or urethra
 are  the  usual causes of this complaint.   Walking, riding, especially
 in hot  climates, and all kinds of friction made by the thighs or by
 external bodies against the scrotum, may also  produce  it.   It is thus
 frequent at St. Domingo and  Martinique, and the West India colo-
 nies  in  general, and likewise  among persons who ride.   Another
 cause of hydrocele, which has been too much overlooked, is found in
 the diseases of the seminal gland itself.  A  great number of persons
 in fact  have  had  an orchitis before  having  a hydrocele.  Paying
 exclusive attention to  the inflammation of the testicles,  they  sup-
 pose themselves cured when this  ceases to  give them pain, or when
 theoigan has been reduced to a moderate size.   Several months pass
 by without their thinking any more of it.  During this time the slight
 irritation remaining in the scrotum excites  an exhalation  from the
 tunica  vaginalis;  a hydrocele is slowly developed, and  when the
 patient  notices it he no  longer knows what to attribute it to.  It is
 also  very usual to see the  testicle, and especially the epididymis,
 bosselated, hypertrophied, and double  or triple  its  size, in hydroceles
 which  are the most simple in their appearance, and which seem to
 have come on spontaneously.  The progress of a hydrocele is usually
 quite tardy.   If some  patients state that they  have seen it develope
 itself suddenly, this is because they have been  almost always uncon-
 scious of its first stages, until chance  suddenly draws their attention 
HYDROCELE.
377
to it.  As  for the rest, it rarely happens that it becomes developed
in less than a month, or that it requires over two  years to fill up the
tunica vaginalis.  Having reached this stage, it may remain station-
ary for  several years.  While, on the contrary, the sac which con-
tains  it  still remains flabby,  it may continue to increase.  Finally, it
invades the entire scrotum, makes traction upon the skin in the neigh-
borhood, conceals and deforms the penis, and may acquire a consid-
erable volume.
  II. The  morbid anatomy of hydrocele teaches  us that the altera-
tions of the scrotum  vary according  as  the disease is recent or an-
cient.   They are all  referable to  the effused matter, to the testicle
and  the tunics which  form the cyst.
  a.  The  liquid in hydrocele is usually a pure  serosity, and  of a
slightly lemon-colored tint, like that of ascitic dropsy.   Albuminous
flocculi are sometimes found  suspended  in or  mingled with it.  It
was lactescent in a patient whom I operated  upon in the month of
August, 1836, and perfectly green, or of  a porraceous green in a pa-
tient of M. Salacroux.  M. Bostock, who has analyzed it, has ascer-
tained that it contains shining colored fibrils (paillettes) whose char-
racter he was not enabled to determine.  There have been frequently
found in it also concretions, sometimes free, at other  times adherent,
of a friable or fatty or mica-like matter,  or clots  of  a fibrinous and
cartilaginous appearance. t It has appeared to me that such products
resulted from a certain quantity  of blood or some perverted albumi-
nous matters.  The chocolate matter which has been so much spoken
of, indicates an ancient hematocele and not a hydrocele.   Exclusive
of a yellow, whitish, or greenish color, the changes in the liquid con-
tained in the tunica vaginalis  are  imputable to  the fact, that it has
been mingled with blood, which in the course of time  has decom-
posed or ceased to become recognizable.
  b.   Thickness of the cyst.—The plates or friable bridles of more or
less  firm  consistence, and sometimes cartilaginous  in their appear-
ence, and which irregularly line  the interior of the sac, and are often
strongly adherent to it, are  also the  remains of effused blood  and
consequently of a former hematocele.  False membranes  that were
purely of an albuminous character could alone belong to hydrocele,
but they are uncommon.  They are distinguished from  the preced-
ing in this, that they become organized in the manner they do  upon
the surface of the pleura, or are so intimately united with the tunica
vaginalis, that it is next to impossible  to  isolate  them from it, while
the fibrinous concretions on the  other hand may be detached with-
out any great degree of difficulty.   These  are  the tissues which
sometimes  transform  the sac into a  thick  hard fibro-cartilaginous
shell.  It is nevertheless true, although this has been denied, that the
tunica vaginalis itself and its immediate  envelopes then  actually un-
dergo a certain degree of thickening by becoming blended with each
other.  It is also  true that this species of lesion  does not belong to
hydrocele  properly so called, but that it is a consequence  or accom-
paniment of simple or complicated hematocele.   In  hydrocele, how-
ever voluminous it may be, the skin is but slightly attenuated, because
the tumor  in becoming developed draws  upon the skin of the neigh-
boring regions.   The same thing takes place in respect to the super-
   vol. in.                      48 
378
NEW ELEMENTS  OF OPERATIVE SURGERY.
 ficial sub-cutaneous fascia; the dartos, which is  the  tissue we next
 come to, is sometimes  attenuated; while  in other cases it becomes
 thicker and assumes a decidedly muscular appearance.   The deep-
 seated  sub-cutaneous fascia of the abdomen,  the divergent sheath
 and that of the  ring,  which  separate it from  the  cremaster, are
 in  most cases, wasted, attenuated,  or no longer recognizable;  in
 some cases the cremaster  is reduced either in  part or wholly to the
 condition of a  fibrous  membrane; while in other cases, it is seen to
 be  manifestly thickened.  The  prolongation of the intermuscular
 fascias, of the fascia transversalis and the fascia propria, expanded out
 upon the surface of the tunica  vaginalis  below the cremaster, are
 more often worn away or  thickened  from  space  to space, than infil-
 trated or transformed into lardaceous tissue.  The  elevations and
 prominences that are sometimes  presented by the tumor, are  owing
 to this, that the fibres of the dartos, and of the  prolongation of the
 ring, and of the cremaster, have allowed themselves to be elongated
or separated apart by the  distended  tunica vaginalis.  These differ-
ent  tunics,  however,  preserve  their  pliancy and  all the  other char-
acters they possess in the normal state.  They are only altered me-
chanically,  and with the exception of a few rare cases, we do not
meet here with any evidence of a pathological process.   It is  from
having failed to make a proper distinction  between hematocele and
hydrocele, that a great  number of facts have been related in oppo-
sition to what I here advance.
  c Testicle.—That which is most variable in the morbid anatomy
 of hydrocele, is the condition of the testicle. When the  disease has
 begun in the tunica vaginalis, the testicle is usually slightly shrunk,
 flattened, and wrinkled, and in  some cases  actually atrophied ; if on
 the  contrary an orchitis have previously existed,  there is  an evident
 augmentation in its volume, but without any other appreciable alter-
 ation.   The epididymis, now indurated and bosselated, is prolonged
 upwards, downwards,  and upon each side, in such manner as to
 spread beyond the seminal gland itself.  All this,  however, is usually
 restricted to mere hypertrophy.  ^Small hardened and whitish-color-
 ed kernels or actual cysts may exist on the surface of these organs,
 and present the appearance of having been developed in the tissue
 of the tunica  albuginea.   I  have seen a cyst  of this kind acquire
 the  volume of a nut.   In such cases the tunica vaginalis will be fre-
 quently found to have contracted adhesions in  the form  of bridles,
 and in such manner that its cavity has become divided into  several
 compartments.   I have seen many patients at La Charite, in  whom
 the  hydrocele had been constituted in this  manner, of several cysts
 each containing one or two teaspoonsful of serosity.   I operated
 upon a patient at La Pitie  in 1834, in whom the tunica vaginalis had
 been transformed into an  infinite number of similar  compartments.
 Is it not one of these conditions which was noticed by Schmucker,
 (Rougemont, Bibl. Chir.  du Nord, p. 36,) and  which  M.  Larrey
 has  described under the name of hydatid or vesicular  hydrocele.
 The spermatic cord being  more  or less expanded  and compressed,
is disorganized as  it were by the separation of its constituent parts.
But in other respects it is usually healthy. Its  vessels are almost
alwavs  contracted, while  on the contrary, the  arteries and veins 
HYDROCELE.
379
which are distributed in the tissue of the  scrotum, are very consid-
erably dilated.  There is also, however, sometimes found here a slight
varicocele.
  III. Signs.—Hydrocele is recognized by various signs ; it is gene-
rally  developed  from below upwards, or  from the bottom  of the
scrotum  to the ring of the external oblique.  At first soft, and as
it were fungous, it ultimately becomes tense, and acquires a very
great degree of  density and solidity.
  a. In the  first  stages the form of the tumor does not materially
differ from that of an hypertrophied testicle.  At a later period it
becomes elongated and  pyriform.  Turned in the direction towards
the abdomen, its apex, which is sometimes slender, at others swollen
in the form of a head  or cylindrical, is prolonged in some instances
into the inguinal canal, or between the aponeurosis of the external
oblique and the integuments, but it most usually stops a little below
the ring.  It almost always presents a species of transverse stran-
gulation at  the middle  portion of its length, and especially in front;
which gives to  it the appearance of a gourd.  When this strangu-
lation is very marked, and formed for  example by the ring, and
when a portion  of the tumor has become developed in  the  inguinal
canal, Dupuytren applies to it the name of a bisacculated hydrocele.
Bent into an angle in this  manner upon its anterior surface, the tumor
has greater length than breadth ; sometimes, however, it is as it were
crowded down  upon itself, and remarkably augmented in its trans-
verse diameter; frequently, also, it presents prominences  on other
points, either above or below, or upon its outer or inner side, all
which circumstances are owing to the scrotal envelopes having been
attenuated or distended in an unequal manner by the tunica vagina-
lis.   It sometimes happens that it  preserves  the form  of a sphere,
either uniform  or bosselated, up to  the  period  of its extreme  de-
velopment;  sometimes  also, its  base  is above and  its  apex below,
several  remarkable examples of which have been  seen at La Charite.
  b. The volume of the hydrocele is  no less variable than its form.
Limited in certain cases  to that of a small pullet's egg, it  may in
others acquire the dimensions even of the head of an adult.   In some
cases adherent, as it were, against the ring, we see  it in others pro-
longed nearly as  far down  as the knee.  It may contain from one tea-
spoonful to two, three, and even  four litres of liquid  ; nevertheless, it
rarely exceeds the size of the head of a new-born infant, and usually
does not contain  over from four to ten ounces of serosity.
  c. Its weight is generally less  than one would  at first be disposed
to think.  Being  the same  as that of an equal quantity of water when
the hydrocele is simple and primitive, it becomes  more  considerable
when the testicle is engorged, or when some concrete deposition has
been made in the tunica vaginalis.  The lightness of the tumor also,
is one of the principal signs of its freedom from complication.  These
differences, moreover, are  quite natural, since  the  blood is  heavier
than serum, and  solid tumors still  heavier than  blood, whether the
latter be liquid or coagulated.
  d.  So long as the tunica vaginalis contains but a moderate quantity
of liquid, an actual fluctuation maybe recognized.  At a later period,
however, it is sometimes very difficult to detect the fluctuation or 
380           NEW ELEMENTS OF OPERATIVE SURGERY.
 displacement of  the liquid;  the  exploration,  moreover,  should  be
 made in the same way as in speaking of acute hydrocele.
   e. The pathognomonic sign of hydrocele, and the one which prac-
 titioners have for a long time considered the most certain,  is derived
 from the transparency of the tumor.  To ascertain  this, the patient
 must be placed in a dark room, or for example, upon a bed with the
 curtains closed, and the  scrotum stretched  and raised up, and the
 hand or any other  opaque body applied in  the manner  of a plate
 of wood at its border in front of the tumor, while the surgeon should
 be on one side and a lighted candle held on the other, in such manner,
 finally, that the light cannot reach the eye until after having passed
 through the hydrocele.  By acting in this manner we perfectly dis-
 tinguish the transparent contents  of the  tunica vaginalis, however
 little water it may contain,  from the opaque mass  formed  by the
 testicle  or  epididymis.   It is possible,  however,  that  we  may  be
 imposed upon in this case in two ways:  1st.  A transparency may be
 perceptible though there may be no hydrocele.  M. Roux  states that
 he ascertained this in a case in which there was nothing but a sarco-
 cele.  This transparency may  exist in  some cases from a simple
 serous  infiltration or slight dilatation of the envelopes  of the scro-
tum  in children, and pale subjects, or in whom the skin is  very thin.
If the hand is placed very obliquely,  and the fingers are but slightly
shut  together, and if the light or  the eye are badly arranged, this
appearance of transparency may be  produced by the luminous rays
being reflected back upon the walls of the tumor.   2d. This sign is
quite frequently wanting, first, when the effused liquid does not  con-
 sist of pure serosity; secondly, fluid or concrete blood, and the cho-
 colate or reddish colored matter, or that  resembling the lees of wine,
 or when lactescent, &c, will not admit of it.  It did  not exist in the
 patient whom I operated  upon with M. Salacroux, and  in whom  the
 tunica vaginalis was filled with a liquid  of a deep green  color, nor
 was  it  found  in  another patient  operated upon at  La Charite, in
 October, 1836, for  a  hydrocele in which the serosity was slightly
 turbid.  Again, it is but rarely seen when the envelopes of the cyst
 have acquired a certain degree of thickness, when they have under-
 gone a lardaceous or cartilaginous degenerescence,  or plates of fibrin
 or albumen have  been deposited on  the inner surface of the tunica
 vaginalis.  I  will, however,  add  that its  absence indicates almost
 always  either an opaque  liquid or a deep-seated alteration in the tex-
 ture  of the cyst, and in all cases a  complicated hydrocele or a tumor,
 which belongs rather to the class of hematoceles than to that of hy-
 droceles, properly  so  called.  If blood, in fact, is effused into  the
 tunica vaginalis, it becomes changed and ultimately forms matters re-
 sembling lees of wine, or of a chocolate  or reddish color,  or bridles
 and  concretions of all sorts, together with friable or fibro-cartilagi-
 nous linings in the sac, &c.;  but it may also happen  that  the serum
 will  become separated  from the  cruor, that the coloring  matter
 will  disappear, and that at the expiration of a certain number  of
 months or years,  there will be no longer anything else in  the tumor
 but a citron-colored fluid with the shell  as thick as  it is  hard.   In
 other patients the transparency which existed at first  is  no longer
 found during the space of several weeks, but afterwards  reappears 
HYDROCELE.
381
again in a striking manner.  This is a fact which I have ascertained
in three instances, and a similar  one has been communicated to me
also, by  M.  Berard, the elder.  Sometimes also, the transparency,
when it has once disappeared, returns no more.
   It is easy to furnish an explanation  to these anomalies; and, what
is singular, the clue to this, so to speak, suggested itself on the same
day to M. Berard and myself.  I had made it the subject of a lecture
at La Charite in  the morning, when  this surgeon informed me that
he had communicated the same idea to  the pupils of the hospital of
St. Antoine on the day preceding.  The explanation is this, that  a
certain  quantity of blood is exhaled and effused in any manner what-
ever, in  the  middle of a hydrocele which is more or less ancient.
The liquid  of the  tunica vaginalis from  being  translucent then be-
comes opaque.   If, at a later period, the coloring matter of the blood
disappears, the transparency is re-established.   In the contrary case
the hydrocele remains  definitively transformed into an  hematocele.
As for the rest, the eye is sufficient to ascertain  the transparency of
a hydrocele, if it really exists, while, in other cases, no additional in-
formation will be derived by means  of  the tube of M. Segalas, or
reflecting mirrors of whatever description they may be.  When the
transparency is wanting it must be imputed to the alteration of the
sac or of the effused liquid, and not to the imperfection of the explo-
rative means made use of.  A circumstance, however, which might
lead to ambiguity to a certain extent, is  the position of the testicle
and of  the cord.   We generally look for the transparency in front,
upon the outside, or above, because the testicle is almost always
crowded to the inside, and  downwards and backwards; but if the
testicle  should be found by anomaly, either in front, as I have seen  it
in four or five instances, or  immediately  upon  the inside or  outside,
we may, in fact, conceive it possible for it to be placed in such man-
ner, between the  eye and  the light, as  to deceive the surgeon on
a rapid  examination.  The error in a case like this would, to a cer-
tain extent,  be  pardonable,  especially if there were present at the
same time a tumefaction or disease  of  the epididymis or  testicle.
The diseases which have sometimes been confounded with hydro-
cele, though of various  kinds,  may be referred to two classes, those
originating in the seminal gland and those disconnected with it.   All
the modifications of sarcocele belong to the first class, while the sec-
ond  is composed of enterocele, epiplocele, varicocele,  hematocele,
cysts and adipose or other tumors, which are developed either in the
scrotum or in the inguinal canal.  A pupil pointed  out to me in the
septum of the scrotum upon the dead body, an ovoid, uniform  and
movable tumor, which might have easily led to deception if it had
been less heavy.  A tumor of  the same kind had already been men-
tioned by M.  Malere, except that it contained four  pounds of water
and resulted in the death of the patient.
  IV. a. Prognosis.—Chronic hydrocele, left to the  resources of
the organism, will  continue for an indefinite  length of time, and
scarcely ever disappears.   The cases of spontaneous cure which are
related,  are such rare exceptions  that it would be impossible to count
upon a termination  of this kind.   Hitherto I have met with but  a
single example, which was in  a  child seven years of age, in whom 
382
HEW ELEMENTS  OF OPERATIVE SURGERY.
 the tumor was of the size of a pullet's egg, and had existed for fifteen
 months.   It completely disappeared in "the space of ten" days ; but a
 month later  I perceived that the serosity again began to be effused
 into the tunica vaginalis.
   b. Accidental laceration of the cyst.—It is  nevertheless  possible
 that the hydrocele may be dispersed,  at least for the space of some
 Weeks, without  any treatment, but in  such cases it is owing to the
 action of some violence which, by tearing  the  cyst, has  forced  the
 liquid to infiltrate itself elsewhere.  Bertrandi relates an example of
 this kind; the patient, having indulged to excess in drinking, found
 himself pressed by an urgent desire to  urinate.   The case mentioned
 by Sabatier was attacked with a violent cough, and M. Krimer also
 speaks of an effort made in the case which he cites.  A similar re-
 mark is  applicable to the case communicated  to  me by M. Serre.
 The patient mentioned by Loder had  received a kick from  a horse.
 A similar fact was seen at La Charite in 1836.   In another  patient,
 however, in whom the hydrocele disappeared during the night  pre-
 ceding the day on which he was to be operated upon, there was no
infiltration observed in the scrotum, nor had there been any violence ;
but the fact was not accompanied with sufficient details to enable
me to come to any conclusion in relation to it.  Such results, how-
ever, are easily explained.  An effort, or some pressure  or  concus-
 sion, tears  or lacerates  the tunica vaginalis,  when  the  serosity is
 effused and immediately infiltrated either into the spermatic  cord or
 in the direction of the inguinal canal, or between the different layers
 of the scrotum, and even into the parietes  of the abdomen, as in the
 patient of M. Lacordere.   In  such cases  the  cyst shrinks, and is
 succeeded by an oedema of the cord, scrotum, or penis, which  oedema,
 in general, disappears quite rapidly when the patient is  neither far
 advanced in age nor of a shattered constitution.   Moreover, it rarely
 happens, in such cases, that the cure continues permanent.   In  the
 patient who fell  under my care the infiltration continued but for  the
 space of three days, and the hydrocele returned soon after.   At the
 expiration of three weeks it was already perceptible.
   In a patient who had ruptured it against the pummel of a saddle,
 the tumor at the expiration of six months had acquired its primitive
 volume.  The same thing took place in  the cases related by Bertrandi,
 Sabatier, Boyer  and M.  Nocelet, (Gaz. Med., 1838, p. 156,)  and  if it
 has not been always observed, it is because the persons who have met
 with these injuries have  not probably been seen again  a few months
 after the accident.  Thus it is  in reality the hydrocele which is re-
 formed after having been effused by means of a rupture, and not as
 might be at first supposed a hydrocele  which is discovered after hav-
 ing been temporarily masked by an accidental infiltration.  When the
 hydrocele is of a large size,'this infiltration  by spreading to the penis
 and walls of the abdomen, in some cases gives a volume to the scro-
 tum which becomes alarming to the patient.  M. Roux was consul-
 ted in 1828, for a case of this kind, and the physician himself, though
 very skilful,  was somewhat alarmed.   The ecchymoses moreover,
 which are sometimes  associated with  it, might  in certain cases give
 rise to the supposition of gangrene, if the practitioner was not acquain-
 ted with this accident from hydrocele.   The cases, moreover, which 
HYDROCELE.
383
I have collected, prove that it is unattended with  any danger.  A
suitable suspensory, some topical resolvents, and a  few days of re-
pose,  will be sufficient to remove the oedema, which probably would
even be dissipated without these means.  The patient mentioned by
M. Serre was so satisfied of this that he caused the dispersion of his
hydrocele by rupturing it as often as it became  too troublesome.
   V.  Treatment.—Hydrocele may be subjected to two modes of
cure,  one palliative, and the other radical.
   a. Palliative cure of Hydrocele.—The operations to which patients
affected with hydrocele were formerly subjected, were so painful and
uncertain in their results, that the question  might well  be asked,  if
they were not worse than the  disease itself.  Thus we see, de Vigo
prescribed simply that the  tumor should be emptied twice a year,
while Paracelsus absolutely  forbade an opening  to  be made into  it.
At the present  day also, it frequently happens that the surgeon is
obliged to  follow the process of J. de Vigo, in some cases, because the
patient exaggerates the danger of the operation  or is too timid  to
submit to any ;  in other cases, because it is impossible for him to sus-
pend his occupations  and to continue eight days at rest; and some-
times also  because he is too  advanced in age to feel the necessity of
a radical cure of an infirmity of so little importance.   We confine
ourselves therefore, in these different  cases,  to emptying the tunica
vaginalis so often as its distension becomes too annoying.  As the effu-
sion almost scarcely ever fails to be reproduced soon after, and as we
are thus obliged to repeat the  puncture every two, three, four, six, or
eight months, this mode of treating hydrocele has taken  the name of
the palliative cure.  The operation is  performed in the same way as
in the method for injections, of which in reality it constitutes the first
stage.  The patient may remain seated or stand up.  The point of a
lancet or of a bistoury could, in these  cases,  be substituted without
any inconvenience for the hydrocele trochar.  Then however,  it
would be advisable to glide a probe into the wound, in order to pre-
serve its parallelism during the discharge of the liquid.   The whole
operation is less  important than a simple bleeding, and no precaution
is required either before or after.  The. patient operated upon may
resume his occupations  on the same day, with the  condition only
that he should wear  a suitable suspensory, and  not fatigue himself.
In general, the cyst fills up again in  the space of one to three months ;
sometimes, however,  and I have seen many instances of this, the
hydrocele does not return to the same extent, until after the expira-
tion of more than a year.  In certain cases, which are  more rare,  it
does not  return at all.  In some  cases too it happens, and these also
are exceptions, that after the puncture  the tunica vaginalis becomes
inflamed to such extent as to enter into suppuration, and to transform
its cavity into an actual abscess.  One of the patients in this condi-
tion, who fell under my observation, caused me  during  eight days a
considerable degree of alarm.   The fever  was intense, and the in-
flammation reached a portion of the iliac region.  It became neces-
sary to open the tumor largely at several places, and the cleansing of
the abscess was not effected until after the expiration of several weeks.
M. A. Cooper also mentions a case in which the simple puncture gave 
384
NEW ELEMENTS OF OPERATIVE SURGERY.
 rise to very serious accidents, and he recollects another in which it
 was followed by death on the sixth dav.
   b. Radical Cure.—The thesis of M. Lesueur contains the evidence
 that leeches and derivatives have in several instances succeeded in
 curing  hydrocele.   On the other hand, we see that Dupuytren  has
 effected a cure in several instances by means of blisters applied over
 the tumor, and other practitioners have related various facts in sup-
 port of this last  practice.  According  to Bertrandi, moxa in some
 cases has been  no  less  efficacious.   M. Graefe, as Keate had also
 done in 1788, extols a solution of muriate of ammonia in alcohol  or
 vinegar of squills.   I have  myself seen a hydrocele dispersed in
 two instances by astringent cataplasms and  mercurial frictions ;  but
 these exceptional cures are scarcely ever met with except in cases
 of hydroceles that are not very ancient or  those which are small in
 size, and which have been caused by either a traumatic lesion or an
 irritation the source of which we are enabled to remove.   In the two
 patients whom I saw cured, the disease had  existed only for two
 months and had  been produced by a blenorrhagic engorgement of
the testicle.  Blistering,  muriate of ammonia  dissolved  in water 01
in coarse red  wine,  and  the most active astringents have  been used
without any benefit  in my department on other  patients, in whom  the
hydrocele had only  existed however for the  space of six weeks, and
had been occasioned by an injury done to the testicles ; leeches and
emollients also had  been  previously employed  with a similar  unsuc-
cessful  result.
  1.  The operation selected for the radical cure of hydrocele has
varied in a remarkable manner since the time of Celsus.  Incision of
the tumor, excision  of a  portion of the sac, scarifications upon  its
interior, its cauterization  with caustics or the red hot iron, and the
 employment of tents, meches, canulas, setons and various kinds of
 injections,  have in turn been eulogized in such manner as to consti-
 tute a variety of different methods, the greater part of which have
 been finally proscribed by modern surgery.
  2.  Cauterization, which Aetius describes after Leonidas,  which
 some practitioners  employed by placing an escharotic at the lower
 and others at the upper  part of the tumor,  repeating it until  it had
 reached the liquid, and which some operators preferred accomplish-
 ing by means of an incandescent  metal or the L  shaped cautery
 mentioned by Paul of Egina, was in use as is seen a long time  before
 Guy de Chauliac, to whom Sabatier  appears disposed to ascribe it.
 Preferred by G.  de  Salicet, Thevenin, M. A. Severin and Dionis, and
 revived a thousand times since, it has been eulogized  in England,
 France and Germany; but under whatever form it has been proposed,
 it is a method which should be totally proscribed.
   3. Tents and  canulas, which are less dangerous or at least less
 barbarous, would in my opinion  deserve the same proscription, had
 not  certain surgeons of distinguished  reputation  in our time still
 thought it advisable to accord  to them a certain  degree of approba-
 tion.   The use  of tents, far  from being ascribable to Franco,  F.
 ab Aquapendente or Moinichen, as Sabatier and Boyer would lead us
 to suppose, goes back as  far at least as to the time of G.  de Salicet,
 who, in speaking  of hydrocele, expresses  himself in these terms : 
HYDROCELE.
385
" Let the scrotum be perforated with a  lancet, the water be drawn
out and a tent introduced into the aperture, in order that you may
freely, whenever you desire, extract what there is within the tumor."
Only  that in place of a process so simple, F. de  Hilden has advised
that we should ligate the  tunica vaginalis, and then incise it and leave
a thin meche in  it, a process which  Bell has  followed with this last
intention.  Monro, imitated in our time  by M. Guerin,  (Rey, These,
No. 79, Paris, 1834, p. 89,) recommends that we should irritate the
serous tunic with the extremity of  the canula of a trochar, and M.
Larrey, that we should leave  permanently in its interior during the
space of several  days the extremity of a gum-elastic sound.  Though
it be  unquestionable that  we are indebted to the employment of these
means for a certain number of successful results,  it is equally certain
that  instead  of  producing a simple adhesion of the surfaces they
very  frequently  cause them to suppurate,  and that  they do not suc-
ceed  sufficiently often to supersede the methods that are generally
adopted at the present day.
  4.  The same must  be said of the  seton, of which  Sabatier finds no
mention in the  ancients, and  which Sprengel ascribes to Lanfranc,
and M. S. Cooper to  Franco, though Galen probably had  reference
to this when he  mentions that we should extract  the water from the
scrotum by means of a syringe or a seton.   It was also on account
of the recommendation  of the physician  of Pergamos that Guy de
Chauliac advises that we  should grasp " the scrotum by  means of flat
tenacula with holes at their extremities, in order to perforate it, by
passing through  their opening a long needle, in the head of which
was inserted a  seton which was to be  left  in the wound until the
water was evacuated."   It would  seem moreover, as has been re-
marked by Leclerc, that C. Aurelianus  had spoken of this process.
Peyrilhe also considers that  he has  found  the suggestion in  Paul  of
Egina.  Though Pare, and almost all authors, had recommended it
up to  the termination  of the seventeenth  century,  this method, which
is censured by Pigray, was nevertheless almost  wholly abandoned
until Marini and Pott undertook to bring it again  into  repute; but
there  is no reason to suppose that the seton, which  is still employed
by M. Green, (The Lancet, 1829, vol. XII., p. 388,)  will be hereafter
preferred by any person.   However, if any person should again de-
cide upon employing it, the name itself is a sufficient explanation, and
nothipg more is  required than  to recollect  that a  ribbon of fine linen
or a long meche of cotton, or any other substance, is to be passed
through the tumor, in order to enable  any one  to  comprehend the
mode  of performing an operation of this  kind.
  5. M.  Van Onsenoort, who employs the seton under the name of a
ligature, makes use of a semicircular needle with an eye near its point.
In an  ordinary hydrocele, he supposes the tumor to be divided into
three  equal parts by two transverse  lines.  Introducing  his needle  at
the  upper line, he brings it out at the lower, extracts the serum, and
then withdraws the needle and tightens  the ligature by means of a
bow-knot.  In large hydroceles, the needle containing a double liga-
ture is introduced at the middle portion of the tumor.   After having
brought out its point  above the  upper imaginary line,  he  separates
one of the threads from it and repasses his  needle into the interior of
  vol. in.                     49 
386
NEW ELEMENTS OF OPERATIVE  SURGERY
 the tumor, in order to bring it  out  below the lower imaginary line.
 The second thread being now disengaged  from it, and  the  tumor
 emptied,  he divides the noose which corresponds to the opening
 where the needle entered, in order  to have two  ligatures  which are
 knotted separately.   In a double hydrocele, a single ligature is pass-
 ed obliquely through the septum  from above downwards.   These
 ligatures, which are slightly tightened at  first, and tied with a bow-
 knot, in order to be  afterwards tightened  again  at pleasure, accord-
 ing to the degree of inflammation, should be sufficiently  strong to
 effect the section of the parts which  they embrace.
   6. M. Kerst having perceived that the" serum  flows with difficulty
 through the opening made by the instrument of Onsenoort, and that
 infiltrations and abscesses frequently take place, has proposed a trochar
 needle whose curvature forms the quarter segment of a circle of three
 inches and a half in diameter.   The  body of the needle  is pierced
 near its point, and its canula has two lateral openings near the up-
 per extremity.  It is introduced in the  same manner as the needle
of M. Van Onsenoort.   The  thread  is disengaged and the needle
 withdrawn.  The serosity then runs freely through the canula, which
is gradually brought out in proportion as the tumor becomes evacu-
ated, and finally withdrawn through the lower opening.
  7. To treat hydrocele with the seton, we ought, says Al. Laugier,
to traverse the tumor with a  trochar, then withdraw the stilette of
this instrument, and introduce into the canula an eyed probe furnished
with a seton; then  return  the  canula into the tumor, which now
only commences to empty itself;  and when it is empty, finish  by
withdrawing the canula  and  leaving  in the  seton, the extremities of
 which latter are afterwards tied with a loose knot.  But it is difficult
 to comprehend the utility of such processes after having been wit-
 ness to the successful results and the simplicity of  the method gene-
 rally adopted in France.
  8. Incision.—Incision, which was made use of at the time of Cel-
 sus and Guy de Chauliac, is performed  by means of a straight or
 convex bistoury.  The  patient  is laid upon his back with  his limbs
 moderately flexed, while the surgeon grasps the  scrotum on its back
 part with his left hand, and in this  manner makes the tumor  tense.
 With his right hand he incises its upper portion, in penetrating from
 without inwards if he uses the convex bistoury, and by a puncture if
 he employs  the straight bistoury.   The opening  at first should  be
 sufficiently large to  admit of the introduction of *he finger,  which
 latter should be replaced by a  grooved  sound, if through  inadver-
 tence we have made too small an incision. A blunt-pointed bistoury
 then answers for completing the division  of the  entire anterior wall
 of the cyst, cutting with it from above downwards, and from  within
 outwards.   As our object is to produce an adhesion of the two mem-
 branes of the tunica vaginalis, by  creating a  suppurative inflamma-
 tion, the wound should  be filled with  lint and dressed daily in such
 manner that the cicatrization can only take place from its  bottom to
 its borders.  By this means we generally obtain a  permanent cure ;
 only that it is not an uncommon occurrence for some points  of  the
 membrane  to escape from the suppuration, and consequently to give
 rise to the formation of small cysts, which allow of the partial repro- 
HYDROCELE.
387
duction of the disease.   The  pain  and accidents  which sometimes
accompany it, and the length of the treatment, have generally caused
this process to be rejected in France, at least since the time that we
nave  come into possession of those that are more simple; so that
Qo'twithstanding the  reasonings of M. Rust, M. Warren, M. Dieffen-
bach, M. Gama, M. Begin, (Elem. de Chir.,&,c., 2d edit., t. III., p. 525,)
md of M. Chelius, (Arch. Gen. de Med., t. IX., p. 230,) who still ap-
pear to give it the preference over every other, this method appears
lestined to form no longer any other than an exceptional resource.
   9.  Excision.—Excision  also appears to have been in use at  the
jme of Leonidas.   We find, in fact, in the ancient authors, that some
of them, after having opened the  tumor, seized, in order to extract it,
the lips of the tunica vaginalis and  rolled them inwards upon hooks.
It is  to Douglas,  however, that we  are indebted  for having drawn
the attention of the surgeons of the last century to this process, and
for the reputation it still retains among us.  There are many modes
of performing it.   The English surgeon commenced by circumscrib-
ing, by means of two incisions,  an elliptical flap of integuments on
the front part of the scrotum, removed this flap and opened the tunica
vaginalis, which he then dissected little by little, until he reached
nearly down  to its adhesions  with the testicle,  in order to excise im-
mediately its two sides by means of a good pair of scissors.   Boyer
recommends a simple incision upon the whole length of the hydro-
cele,  then to dissect the tunica vaginalis as far as possible on the side
of the seminal gland, before giving egress to the liquid, and afterwards
to open the  cyst and excise its flaps.  Finally, Dupuytren found it
more simple to embrace the whole of the tumor underneath with his
left hand, in order to stretch its anterior wall as much as possible,
then to incise, like Douglas or  Boyer, according as it should or should
not be found necessary to remove a flap of integuments, and after-
wards to enucleate, so to speak, the tunica vaginalis by pushing it
from behind forwards, and expelling it, in a word, nearly in the same
manner as we would a kernel of fruit, by pressing  it between the
fingers.  This being  done,  he opens the cyst and excises it in the
manner which has already been stated.  Whatever may be the pro-
cess adopted,  the wound is immediately filled with soft lint, and the
rest of the dressing is precisely the same as after the simple incision.
We see by this description that excision, which  is  still preferred
by M. Fricke, (L'Experience,  t. II., p. 408,) is a painful method, and
necessarily more protracted than the  others.  Its advantages are,
that it does not allow the disease to be reproduced,  since it effectually
destroys the organ which is the seat of it.   Nevertheless, as it is im-
possible to remove the totality of the tunica vaginalis, we cannot per-
ceive  how it can absolutely secure us against a  return of the disease.
Experience, moreover, as Boyer has remarked, has shown that hydro-
cele has sometimes returned after excision as well as after incision:
this, therefore, is another method which is to be rejected in the treat-
ment of simple hydrocele.
   10.  Partial excision  and immediate reunion.—A remark of Pott
would seem to indicate that this surgeon did not look upon the extinc-
tion of the vaginal cavity as indispensable in the cure of hydrocele.
M. Ward even maintains that hydrocele is frequently cured, though the 
388
NEW ELEMENTS OF  OPERATIVE SURGERY.
 serous cavity of the scrotum may have preserved its original dimen-
 sions; and  M. Green (The  Lancet,  vol. XII.,  p. 388,) adduces,  in
 support of this opinion, a specimen preserved in the museum of St.
 Thomas's Hospital.   M. Ramsden is of the same  opinion, and M
 Kinder-Wood, according to M. Walsh, adopted this idea for the  con-
 struction of a  new method.  This surgeon, after having  divided  to
 the extent of a few lines all the tissues down to  the tunica vaginalis,
 dissects, in order to excise it, a small  flap from this  membrane.   The
 liquid being  evacuated, the  wound  is united by first intention, by
 means of one point of suture.  Without participating in the anticipa-
 tions  of M. Walsh or his countryman on this subject, I cannot, how-
 ever,  omit remarking, that a case which occurred in my department
 at La Pitie in  1831,  might perhaps be adduced in support of Pott's
 assumptions.  The patient was over fifty years of age, and his hydro-
 cele was double the size of the fist.   I operated with the vinous in-
 jection, and the scrotum had almost returned to its natural condition,
 when  an attack of apoplexy carried  off this patient on the twenty-
 sixth  day after  the operation.  Being desirous  of ascertaining  the
 progress of the  morbid process, I carefully dissected the parts,  and
 was surprised to find  the  tunica vaginalis entire, with  its natural
 polish, and  containing nothing else in its lower portion than a glutin-
ous filamentous  matter of a slightly green color, and which had not
contracted any adhesion.   The testicle, moreover, and its envelopes,
were  entirely sound.  In two subjects whom I have  since had an
opportunity of examining,  the vaginal cavity, on the contrary,  had
entirely disappeared.  M. A. Cooper  also cites  a case in  which the
tunica vaginalis  was only  imperfectly obliterated;  but could it be
affirmed that the cure, under such circumstances,  would have been
 complete.  If a hydrocele cured by an irritating injection may return
 at the expiration of thirty  years, as  in the patient of M. Ansiaux,
 (Clin. Chir., 2d edit., p. 215,) or after the lapse of some years or
 months only, numerous examples of which exist, is it not evident that
 the tunica vaginalis in such cases has  not been obliterated ?
  VI. Injections.—Almost all modern authors, upon the strength of
 an assertion of A. Monro, attribute the idea of injections, in the rad-
 ical cure of hydrocele, to a military surgeon  of  the same  name as
 this writer.   They had, however, been recommended  and  in  use  a
 long time before. Celsus had already remarked, that if there is  water
 in a pouch, we must, after having emptied it, throw up injections of
 a solution of  nitre or saltpetre.  Lembert of Marseilles, whose com-
 mentaries and observations were  published in 1677, formally states,
 that the best method to be  followed  in the treatment of hydrocele,
 consists in  extracting the water  by means  of a canula, in order to
 be enabled afterwards to inflame the cyst by injecting eau phagede-
 nique into it through the same canula.  His  trials with this process
 inspired him with so  much confidence  that he came to a  resolution
 to employ no other afterwards.   The  eulogiums which were at first
 lavished upon this process by Monro, and afterwards by Sharp and
 Earle. having been weakened by the  unsuccessful  results  of  many
 other practitioners, injections did not get into  repute in England,
 and were in fact not generally adopted in France, until after the me-
 moir  of Sabatier.  As it is at present the only process almost which is 
HYDROCELE.
389
followed, I propose to speak of it in a special man ler, and to enter
more into its details than with any of the others.   There is no ne-
cessity of my refuting the assertions of those who recommend, that
in place of the ordinary trochar, we should make use of one  that is
flattened, or that before  making the puncture we should  divide  the
skin and the subjacent tissues by means of a lancet, since the inutil-
ity of these precautions  is at the present day generally conceded.
Nor is there any longer any necessity of discussing the opinion of D.
Schacci, who  has greatly extolled  an elastic  canula surmounted
with a cutting point, inasmuch as the hydrocele  trochar, either with
or without a notch on one of the sides of its canula, has  been long
since regarded as quite  sufficient in every case.   Though we no
longer differ in opinion, however, on the best instrument to be employ-
ed, nor on the manner of making the  puncture, and withdrawing
the liquid,  it is not altogether the  same with the irritating agent.
   a. Various liquids.—The ancients had recourse, as we have seen,
to solutions more or less acrid.   Lembert made use  of lime-water
charged with corrosive sublimate. The surgeon spoken of by  Monro
employed alcohol, either pure or  diluted with water.   At  the same
epoch red wine was also made trial of.   Earle greatly eulogized port
wine, while Juncker preferred that of Medoc, and Leveret confined
himself to  a solution of  caustic potash.  The solution of sulphate of
zinc, indicated by Bertrandi and  M. A. Cooper, has succeeded  100
times out of 106 cases in the hands of M. Mott.  Boyer and Dupuy-
tren finally succeeded in securing the adoption of red wine, either
simple or with a small quantity of alcohol, or in  which roses of Pro-
vence  have been boiled.  I have seen used, and have used myself
spirits of camphor, to attain the same object,   Cold water, (Beclard,
Fricke, L'Exper., t. II., p. 408,) air, (Gimbernat, Ibid., p. 404—Ma-
nieri, Journ. des Conn. Mid.- Chir., Mai, 1838, p. 215 ; 5 examples.—
Riccardi, Observat Prat., p. 11, 1836 ;) milk, the liquid of the  hydro-
cele itself, a solution of marine salt, of alum, (Gerdy, Arch.  Gen. de
Aled., December, 1837;) nitrate of silver, (Parent,  private commu-
nication, 1838,) and tannin,  (Chaumet, Ibid., 1839,)  have  also been
made trial  of.   When we reflect  upon the result which is to  be  ob*
tained, it is easy to comprehend that these different agents  are in fact
in some cases  calculated to answer the views  of the practitioner.
The object in fact is to irritate the tunica vaginalis, and to  create an
adhesive inflammation in its interior.  Now cold water, wines of all
descriptions, brandy, caustic solutions, in a word  any liquid what-
ever, even  the extremity of a canula or tent, or the presence of any
foreign body whatever it may be, are evidently of a nature  to pro-
duce this result;  the only thing we have  to ascertain is, what suc-
ceeds best, and is attended with the least inconvenience.
  b. Red wine.—Experience up  to the year 1832 having apparently
decided in favor of strong red  wine,  made stronger by a  small
quantity of alcohol, or by having roses boiled in it, I could not un-
derstand at that period why it had been thought advisable to  make
trial of other liquids.  It must be remarked, however, that  alcohol,
rejected by many authors, who  considered it too irritating, produces
no  effects  more alarming than ordinary wine, and  that if I  did  not
adopt the employment  of it, it  was because I had  seen it fail in 
390
NEW ELEMENTS OF  OPERATIVE SURGERY.
   l?e CaSGS 0Ut  °^ e'even patients operated  upon, while  the  wine,
 which I had myself made trial of in about 60 cases, did not fail  but
 in five instances.   Justified  by new experiments, I shall hold at  the
 present day another  language, after having described in detail  the
 vinous injection.
   1. Operative Process.—Before  emptying the  scrotum we are to
 have prepared a  syringe  properly arranged  and of the capacity of
 nearly a demilitre ; we must also  have  at the  same time a litre or
 two of liquid prepared in the way which has been described, and a
 chafing-dish filled with live coals to heat  it.   Sundry basins are also
 necessary, either to contain the wine  for injection or to receive  the
 water of the  hydrocele.   When  every  thing  is arranged in this
 respect, the  surgeon, after the patient is placed upon a bed provided
 with alezes,  embraces the scrotum  in the same manner he does for
 incision or excision, and again satisfies himself that he has an actual
 hydrocele before  him and not another disease  ; also that  the tes-
 ticle  and  various  portions  of the spermatic  cord  are placed in
 certain relations, and  not  in others.  With his  right hand the ope-
rator then takes the trochar armed with its  canula, and plunges it
in  with a short stroke  (d'un coup sec) upon the  anterior, lower and
outer part of the tumor, as far as to the  centre of the liquid.   This
 point is  to be preferred because, in the ordinary state, the testicle
 and its dependencies are found upon the  inner side, and below, and
 behind, and  that it is the  best mode of reaching the middle of the
 vaginal tunic.   It is unnecessary to say that  if a different arrange-
 ment had been ascertained to  exist before commencing the opera-
 tion, the instrument should have  been carried in another direction
 and upon the point which would appear to be the most suitable; the
absence  of  resistance, a  small  drop  of liquid, which sometimes
escapes  between  the wound and the canula, the  depth to which we
have reached and  the void in which the point of  the trochar appears
to  be situated,  sufficiently indicate that  the instrument  has entered
 into the cyst.  The surgeon  then embraces the canula near the skin
 with the two first fingers of his left hand, and immediately withdraws
 the stilette, in order to enable the liquid to run out.   When the sac
 is  partially emptied he presses it in  every direction, taking care that
 the beak of  the canula does  not become embedded between the en-
 velopes of the scrotum.  Up to that time also, the beak of the instru-
 ment must  not be allowed to reach  the inner  side of the morbid
 cavity in such manner as to interrupt  the egress of the liquid.  An
 assistant immediately fills the instrument with  the injection, which
 should be of the temperature of about 32° Reaumur,  or  more, if the
 tissues of the patient should  appear to be but  slightly irritable, or
 when the liquid itself is not very irritating, but  under contrary cir-
 cumstances, the temperature should be a little less, at such tempera-
 ture, in fact, that  the hand may support it. but with some degree of
 inconvenience.  The syphon of the syringe is then directed into the
 external opening of the canula, to which it should have been applied
 beforehand, in  order to be sure that it is exactly  adapted to it.  The
 assistant then gently pushes upon  the piston  until the instrument is
 empty or the cyst filled with liquid  ; the operator constantly support-
 ing the  canula near its root, prevents it from butting against the inner 
HYDROCELE.
391
 side of the sac, or from being withdrawn so much as to become en-
 tangled  in the tissues of the scrotum, while at the same time, with
 his forefinger he shuts it and prevents the escape of the liquid  at the
 moment when the assistant has removed the syringe.  An additional
 quantity of the injection is now immediately thrown up in the same
 manner, or more if necessary, in order to give to the tumor as  much
 volume  nearly as it had  before the operation.   It is to be retained
 each time within the tunica  vaginalis for the space  of three minutes
 according to some  practitioners, four or five according to others, and
 as some recommend  even  six or seven.   Finally, there  are others
 who advise that the tunica vaginalis should be filled a third time be-
 fore emptying it definitively.  Moreover it is advisable, it is said, if
 not indispensable, to expel from the cavity even the last remaining
 drops of the liquid, and also the air which may have got introduced
 into it, before we remove the guiding canula.
   2. Dressing,  and'natural consequences of the Operation.—For
 dressing, it is the practice to surround the scrotum with compresses
 saturated with wine similar to that of the injection, and to renew
 these compresses three or four times in the space of every 24  hours
 until the fifth or sixth day, that is to say,  until the inflammation  has
 acquired the degree of intensity  desired, and until we may replace
 them by emollient  cataplasms.  In some patients the  inflammation
 acquires its greatest degree  of intensity on the day after the opera-
 tion ; in such cases the tumor is hot, red, and painful, and has acquir-
 ed a size almost equal to that of its original dimensions.   In other pa-
 tients this does not  happen until about the fourth, fifth, or sixth day.
 In a patient whom  I operated upon in  November,  1831, there was,
 so to speak, no pain or swelling  during the first two weeks.   The
 inflammatory symptoms  in another did not come  on until the 10th
 or 12th  day, although he was yet young and very excitable, and
 of a nervous rather than a  lymphatic constitution.  He  had been
 operated upon also the  preceding  year,  and  without  having been
 any more incommoded  by it.  In both  patients  the  success was
 complete.  A febrile  movement, sometimes  even  quite an  acute
 degree of fever,  together  with  all the  symptoms of a  manifest
 general reaction, accompany this local inflammation.  M. Blandin
 speaks of a case in which the inflammation extended  to the veins of
 the cord, and caused the  death of  the patient;  but it rarely happens
 that serious accidents result from it.  The system sometimes even
 appears to be unconscious of what is passing in the scrotum.   The
 matter which is effused in the cavity of the tunica vaginalis has this
 remarkable feature,  that it is  soft, clammy, semi-fluid, and constitutes,
 in every sense of the word,  plastic lymph. There is, however, also
 associated with it, in a considerable number of cases, a certain  pro-
 portion of serosity,  but scarcely ever any albuminous flocculi, or ac-
tual pus.  This effusion continues  while the inflammation is increas-
 ing.  Its resorption  is afterwards effected  by degrees in such  man-
 ner that the  parts may reacquire their natural volume at the expira-
 tion of twenty days, a month, or six weeks, and this process seems
 also sometimes to extend to the envelopes of the scrotum, which were
 more or less thickened, as well as to the testicle, whose tumefaction
is in some respects a necessary consequence of the original disease, 
892
NEW ELEMENTS OF  OPERATIVE SURGERY.
 or of the operation.  While the more fluid parts of the effused matter
 disappear, its concretible portion  is imperceptibly blended with the
 two walls of the tunica vaginalis, which latter  become  so perfectly
 agglutinated together, that there cannot be found ultimately any ves-
 tige of cavity between the testicle and the surrounding tissues. When
 the inflammation begins to diminish, that is to say about  the 8th or
 10th day, emollient cataplasms are generally no longer indicated, and
 resolvent compresses embued with  wine, or vegeto-mineral water,
 should be  substituted in their place.   As  resolution in  some cases
 goes on too tardily, it is advisable to assist it by  suitable means.
 Cataplasms of flax-seed flour, wet with extract of lead, have in many
 cases appeared to me to be advantageous ;  the applications however
 which possess the most efficacy, are mercurial ointment either alone
 or under the form of a cataplasm", also iodureted or hydriodated po-
 mades, either simple or combined  with opium, and employed in small
 quantities in the form of frictions on the tumor.   An important precau-
 tion during the whole course of the treatment is to give perfect sup-
 port  to the  scrotum by means of a good suspensory.   Though the
inflammation may rarely proceed  to the extent of causing  abscesses,
 this nevertheless is an accident which is sometimes seen : then the
 scrotum will be seen  to become red, projecting, and afterwards fluc-
 tuating on a determinate point of its surface, presenting all  the symp-
 toms of a phlegmon or actual abscess.  The indication is the same as
 that for acute abscesses in general.   Thus leeches, if we suppose we
ean prevent the suppuration, and cataplasms, and the opening of the
collection as soon as its existence is clearly ascertained, constitute the
principal treatment.  In other cases, the tumor, after having  dimin-
ished a third, half, or three-fourths of its original volume, continues to
remain in the same state, leaving the cure incomplete.   It is in such
cases that topical astringents and resolvents are especially advanta-
geous. They have been seen to triumph over this obstinacy in the dis-
ease, and to complete the cure at  the moment when it was supposed
 another operation would become necessary.  If finally, nothing should
 succeed, we have still the resource of repeating the operation.
  3.  Precautions to be taken.—The method by injections, such as I
 have described it does not, in the  majority of cases, require any other
 precautions; but if the tumor should be of large size, equal, for exam-
 ple, to the head of an adult or still larger, it would be well to follow
 the counsel of Bertrandi and Schmucker, (Rougemont, Bib. Chir. du
 Nord,  p. 37.) who recommend that before injecting the  irritating
 liquid into the tunica vaginalis, we should make  one or more precau-
 tionary punctures, in order to enable the  scrotum  to  return upon
 itself, and not to be compelled to excite inflammation upon so large an
 extent of surface.  I have, however, operated without this precaution
 on a man  forty-eight years of age, and in whom the hydrocele, which
 was very ancient, was twenty-four inches  in  circumference.   No
 accident supervened, and the cure took place in the usual period of
 time.  During the time the liquid is being thrown up, the patient
 usually experiences a pain, which  is transmitted through  the track of
 the  cord,  and is considered  as  an evidence that the irritation has
 reached  the degree  which is desirable, and some  are even satisfied
 to find that this pain extends to the side and lumbar region, so that in 
HYDROCELE.
393
general quite an unfavorable result is  predicted when this kst is
not  felt.  As all persons are not endowed with the same  degree of
sensibility, and that the tunica vaginalis may be altered to a  greater or
less  extent, all patients will not experience this pain to the same de-
gree.  In persons who are aged, or where the hydrocele  is  ancient,
and  we apprehend a marked thickening in the cyst, it is advisable to
heat the wine to a very considerable degree, or to render  it some-
what more irritating  than  for those patients who are found under
opposite conditions.   Moreover,  it is  not to  be supposed that the
operation will not succeed because the pain in  question has not  been
developed ; experience has  a  hundred times demonstrated the  con-
trary.
   4. Accidents.— Gangrene of the Scrotum.—The canula, as I have
already said,  readily abandons the vaginal cavity while the  scrotum
is retracting  and emptying itself.  This accident, which apparently
is very trivial, may lead to the most serious consequences.   The assis-
tant, under  such circumstances, almost unavoidably injects the liquid
between the  tunics of the  scrotum without being conscious of it;
there results from this an inflammation which almost invariably ter-
minates in gangrene, if in fact it does not at the very first  jeopardize
the life of the patient.   Boyer  was witness to  a case of this  descrip-
tion.  The  surgeon had charged  an assistant to hold the canula while
he himself threw up the injection: a gangrenous inflammation super-
vened, and the patient died.  A similar fact  is related  by M. A.
Cooper,  and  another  occurred in  1836, in one of the hospitals of
Paris.  I saw an accident of this  kind in 1824 ; the integuments and
the  subjacent tissues became gangrenous throughout almost the en-
tire  extent of the scrotum;  the symptoms, nevertheless,  ultimately
subsided, and  the patient was restored.  M. A. Cooper  states that he
has frequently noticed  similar gangrenous inflammations produced by
the infiltration of the wine into the tissues of the scrotum.   This ac-
cident is then indicated,  even  at the very moment of the  operation,
by the pain which the assistant causes in  endeavoring to make the
liquid penetrate, by the resistance which he meets with, and by the
projections which  he recognizes  in the neighborhood of the canula,
and  which latter, moreover, he  perceives does not have its  extremity
acting freely in the  tunica vaginalis.  Upon the supposition  that the
effusion has taken place, it would become necessary immediately to
scarify to a great depth the whole thickness of the scrotum at a great
number of points, and  to go even  somewhat beyond the limits of the
infiltration.  The antiphlogistic treatment  and emollient cataplasms
would be first had recourse to, after which we should make use of
topical resolvents if, in  spite of the means mentioned, gangrene should
become developed or  extend.  Gangrene  of  the scrotum may also
manifest  itself, even though the  injection may have actually been
thrown into the vaginal  pouch.  This  is a fact which is not men-
tioned by authors,  but which, however, does  not appear to  be very
unfrequent.  Many persons  have  stated to me that they had noticed
it, and some intelligent pupils  have informed  me that they had wit-
nessed it in three hospitals of Paris in the course of the same year.
I  have myself collected many remarkable instances of it.  A man,
sixty years  of age, who had a double  hydrocele of moderate size
  vol. in.                      50 
394
NEW ELEMENTS  OF OPERATIVE SURGERY.
 was operated upon by me at the hospital of St. Antoine, in the spring
 of 1829.   The puncture and injection were made only on the right
 side, and the liquid was thrown  up twice into the morbid cavity with-
 out any impediment or difficulty.   The proof that it had effectually
 entered into this cavity is, that we made the whole of it come out
 through the  canula after the last injection, with full as much facility
 as  it  did  after the first.  The  patient, moreover, experienced only
 the usual  pain.  On the  first, second and third day, the swelling of
 the scrotum  followed its customary course; the inflammation con-
 tinued even  quite  moderate; but on the fourth day we perceived  a
 point  mortified on the lower side of the tumor, and though I imme-
 diately proceeded  to  scarify the parts, the gangrene nevertheless
 proceeded  so rapidly that it  involved the scrotum down to the root
 of the penis, and gave rise to the general results which usually accom-
 pany it; we ultimately,  however, triumphed over it.   The sphace-
lated sloughs were  successively detached, and  the globular vaginal
tunic, almost naked at the bottom of the wound, appeared to be filled
with a softish matter, as if nothing peculiar had taken place;  and
after a long course of treatment the cure was accomplished, even
on the side which had not been operated upon.
  In the second case treated at  La Pitie in the month of November,
 1831, nothing could have iriduced us to  suspect  the occurrence of
such an accident, when, on the fourth day, without there having been
any pain, or redness, or any perceptible signs of inflammation, I dis-
covered a  large eschar on the front part of the scrotum.  No reaction
took place, the tissues gradually exfoliated, and the cicatrization was
ultimately  accomplished.   I  have been  witness to three similar facts
since.  In one, everything went  on as in  the preceding patient; in
the two others the part involved comprised only an inch in dimen-
 sion of the  sub-cutaneous tissues of the scrotum.
  In the three patients there was  this  remarkable feature, that the
mortification was not preceded by any apparent inflammation before
the ninth day, and that  it was announced by a simple tumefaction,
accompanied with  crepitation  on   that part of the scrotum upon
which  it was to occur.   Where  can we discover the cause of this
gangrene ?   It is certainly impossible to attribute  it  to the effusion,
by means  of the canula, of a certain quantity of wine between the
tissues  which  separate the  tunica vaginalis from  the  skin, and yet,
nevertheless, there is scarcely any other thing  to which we can im-
pute it, except the vinous infiltration. I  can perceive, moreover, four
ways in which the fact  may be susceptible  of general explanation.
In distending the tunica vaginalis by the injection to  a great degree,
we may readily cause a laceration in it, and the  exudation externally
to it of some few drops of the irritating liquid.  It would not be
surprising  to  me if this had been the result in the second case I have
described.   In him, however, as in  the first, as  the accidents did not
manifest themselves until the fourth day, an explanation of this kind
can scarcely be admitted.  We  ought to  refer it perhaps, in these
two cases at least, to the  existing debility, absence of  reaction and
state of alarm which accompanied  them, and to the  gradual trans-
mission of  the inflammation  from  the interior  to the  exterior.  If
gangrene of the scrotum  can be produced by a simple puncture, or 
HYDROCELE.
395
even without any previous puncture, we cannot see what should pre-
vent its taking place sometimes in the vicinity of a hydrocele, which
has  been  operated  upon with  the vinous injection.   Lacerations
of the tunica vaginalis  being easily made through its fibrous lining,
surgeons should be careful not to distend the parts during the injec-
tion more than they were by the hydrocele itself.  This precaution
is so much the more important, inasmuch  as the wine regurgitating
between the canula,  whether it is notched  (crenelee)  or not, and
the tissues, might possibly become in this manner infiltrated into the
substance of the scrotum.  M. A. Berard, who adopts  this explana-
tion, (Gaz. Med., 1833,  p. 404,) invokes in its  favor a fact which  he
considers conclusive.   Thus is  it a reason, therefore, for dispensing
with the groove which is seen on the outer side of certain hydrocele
canulas.  Too large  a  canula, leaving an opening so wide that  the
tunica vaginalis may afterwards insinuate some drops of liquid into
its track, is also calculated to favor the infiltration in question ; this
is another argument  for making use of a small one.  I would add,
that if a certain quantity of wine  should  be left in the cyst after
the withdrawal of the canula, it is readily perceived that this liquid
might become infiltrated through the puncture and give rise  to the
same accidents; so that we ought to  empty the tunica vaginalis as
perfectly as possible  before withdrawing  the instrument, and after-
wards abstain from making any  kind of pressure whatever upon the
scrotum.
  5. Two other accidents,  viz., hemorrhage  and  puncture of the
testicle, may also accompany the operation for hydrocele.  The first,
which J. L. Petit  was the first to point out, and upon which Scarpa
has dwelt so earnestly, can arise only from three causes:  1st, from
the wounding of the arterial branches supplied to the scrotum, by the
external and internal pudic arteries or by the epigastric ; 2d, from
a puncture of the vessels  of the testicle ;  and 3d, from  a simple
sanguineous exudation upon the inner surface of the tunica vaginalis.
From whatever cause it may arise, we can scarcely comprehend any
immediate  danger from it.  None  of these vessels  are sufficiently
large, at least in their natural state, to make their  division in reality
alarming.  As to the means to be employed, they resolve themselves
into that of making a free opening into the sanguineous collection,
should its resolution be too tardy in being accomplished, or should there
be apprehension of any serious symptoms.  Moreover,  it  would  no
longer be a hydrocele which would have to be treated, but in reality
an hematocele, as in the case related by M. Macllwain.
  6. Puncture  of  the testicle can only take place  in those cases in
which it has been impossible to identify with  precision  the situation
either of the spermatic  cord or  of the seminal  gland itself.  There
is danger of it also  when  the hydrocele is but slighty developed.
Dupuytren, Boyer, and almost  all  surgeons of somewhat extensive
practice, have had an opportunity of noticing it.  The pain which it
produces, and which is very acute in certain cases, possesses a pecu-
liar character which prevents the possibility of any ambiguity.  The
organ sometimes becomes violently inflamed, and may be  destroyed
by  suppuration; nevertheless, this wound is attended with  fewer
dangers than would be at first supposed.   A patient wounded in this 
396
NEW ELEMENTS  OF  OPERATIVE SURGERY.
manner, and in whose testicle the extremity of the canula had only
entered so far that the injection itself could detach it, scarcely expe-
rienced any other symptoms than  those  which ordinarily  accom-
pany the operation by injection.   In another, however, there super-
vened an abscess which I laid open, and which, during several weeks,
gave me much apprehension that the seminal organ would be de-
stroyed.  In two other cases I have  seen the effects of this puncture
entirely disappear on the following day.
   7. Emphysema.—A final complication of injection is the retention
of a certain quantity  of  air or gas in  the  tunica vaginalis.   I have
seen several examples of this; among others, two in which the crepi-
tation continued during  the space of nearly fifteen days.  In these
two  cases, however,  as in the others, no serious results  took place,
and  the cure was effectually established.   In other cases resolution
was  not effected, and  I consider it proper that we should be on our
guard against this complication, which, in my opinion, throws a doubt
on the efficacy of air  injections.
  VIII.  New methods.—I have been a long time persuaded, from the
inconveniences  and dangers of vinous injection, that we would  be
authorized or even compelled to have recourse to other or new re-
sources.
  a.  Acupuncture was the first  remedy that presented itself to my
mind; a young physician had informed me, moreover, in 1831, of a
case  in  which the  patient was  cured in  eight days by the simple
puncture of a long needle which had accidentally been introduced
into  the scrotum, though his hydrocele had  existed for a period of
three years.  M. Moro has published  a case no less remarkable:  it
is that of  a hydrocele which was cured in six days  by perforating
the scrotum with a needle, which was left in the parts in the manner
of a seton.  It would appear also that in India this is a common
method  with those  who do not employ puncture at first, followed by
a meche.  In consequence of these facts I made trial of this process.
Two patients were submitted to it  at the hospital of La Charite in
July, 1836, but neither of them were  cured.  In two other  cases I
introduced a simple thread, crosswise, through the tumor, instead of
leaving  in the needle; I withdrew the  small setons on the third day:
suppuration supervened, and the cure was effected, but more tardily
and  with greater inconveniences than with the vinous injection.   I
consider, therefore, that acupuncture,  whether with or without the
threads, is a process which should be wholly  proscribed in the treat-
ment of hydrocele.   Having in four  other  patients  made  trial  of
puncture with needles until  a small drop of serum made its appear-
ance, as recommended by M. Lewis, I found the hydrocele diminish
and  even  disappear  from day to day,  without infiltration;   but the
effusion nevertheless   was reproduced, and a permanent cure  not
effected in any of the patients.   This method, made trial of success-
fully by MM. Hacket (Lancet, February,  1837, p. 787,) and King,
(British Annals of Med., No. I., p. 13,) did not succeed in the hands
of M. Davidson (Gaz. Med., 1838,  p. 72,) and M.  Davey, (Lancet,
February,  1837, p. 741,) and certainly was  not of sufficient impor-
tance to be claimed  in honor of M. Travers, (London  Med. Gaz.,
Feb., 1837,) or M. Cumin, (Ibid., March, 1837, p. 866,) as it has been. 
HYDROCELE.
397
  b. Compression.—I asked myself the question in 1832, whether a
methodical compression, executed  by means of a retractive plaster,
might not sometimes succeed in curing this affection in those persons
who were  not willing to  submit, or who could not be subjected to
any of those operations  which are generally considered  capable of
effecting a radical cure.  In consequence of this suggestion, strips of
adhesive plaster, which, when properly applied, so promptly cure an
acute orchitis, were made trial  of by me on three patients in the
course of the months  of September and October, 1836.  Though the
scrotum comprising the testicle on the diseased side  were immedi-
ately enveloped with  these plasters after the  puncture, in such man-
ner as to place and to  keep  in contact the two walls of the tunica
vaginalis, this did  not  prevent  the liquid from being  reproduced.
This method therefore should also be  proscribed.   Every thing  in-
duces me to  believe that  such will not be the fate of the following
process.
  c Iodine Injections.—Having understood  that  preparations  of
iodine had been  made use of as  topical  applications in hydrocele,
and that cures had  been ascribed to them, imputed to  their resolvent
virtue in glandular engorgements, it also occurred to me that I would
use them in the form of injection.  For that purpose I made use of a
solution  or mixture of water and the alcoholic tincture of iodine.
After having emptied the  cyst by the ordinary puncture, I injected
into it the liquid  in question.  It  is unnecessary to fill  the vaginal
tunic with it, provided  by kneading (malaxant)  the tumor we force
the liquid to come in contact  with the whole of its interior.   We im-
mediately withdraw the whole of it, but without any danger, should a
small quantity of it be  left behind.  As it is not  necessary to heat
the inje.ction, nor to fill the cyst with it, nor to extract every portion
of it, the syringe usually employed  for injections of the urethra might
be made to answer;  and if  the hydrocele should  be  voluminous, it
would be sufficient to fill it three or four times.  After the  injection
the patient is not obliged to keep  his bed.   The part continues to
swell during three or four days, but without  causing fever or  any
severe pain;  resolution  then  commences and is generally promptly
completed.  I have used  this method in more than one hundred
cases.   None of  the  patients have experienced the  slightest acci-
dent ; most of them were cured in less than twenty days.  In four the
resolution was only half completed upon  the thirty-first day ;  I re-
peated the operation, and the  cure  then was promptly  effected.
Seven  had already  been unsuccessfully operated upon by the vinous
injection or cauterization ; six had  an encysted  hydrocele of the
cord; in three the tumor contained about twelve ounces of  serosity;
in twenty-five the testicle was hypertrophied, bosselated,  and  dis-
eased for a long time; in all except one the malady had existed over
six months ; and  one had  been  effected with it for fifteen, and an-
other for twenty-four years. In  using the tincture of iodine as a
substitution for wine,  there is no necessity for a  chafing-dish or par-
ticular kind of syringe, nor of any preparatory  means.   As we are
not obliged to distend the tunica  vaginalis, we run no risk of causing
a reflux of the liquid,  or of forcing it into the tissues of the scrotum.
As  it is an absorbable substance, its infiltration does not seem to ex- 
398          NEW ELEMENTS OF OPERATIVE  SURGERY.
 pose  as  much  to  the danger of gangrenous inflammation as wine
 does; and there is no necessity of its being retained  in place longer
 than from five to ten minutes.  I designedly left an ounce of it in the
 cyst,  and the cure  was only so much "the more rapid.  The reaction
 of the pain  in the lumbar region is nothing.   Patients usually suffer
 but very little, and may  get up and walk on  the following day with-
 out any serious inconvenience.  A young man  who  had  been  sub-
 jected to the vinous injection  without any benefit, came from  the
 city to be operated upon that morning at the hospital, from whence
 he returned  home, and afterwards  continued to go out  daily.  An-
 other patient whom I operated upon in presence of MM. Parent and
 Nicolas, took his daily walks without the cure  being thereby inter-
 fered  with.  The cure is more prompt, and full as complete, as with
 the wine.   One of the  patients whom I treated in this manner in
 1835,  and who was cured by the tenth day, afterwards died in con-
 sequence of an amputation of  the leg.   The scrotum, which  was
 carefully dissected, showed  that intimate cellular adhesions had been
 established between all the  points of the vaginal cavity, and that any
return of the disease would have been impossible.   With this liquid
a syringe of the capacity of from three to four ounces is  sufficiently
large  for all cases;  only that it would be  necessary, if we  should
make  choice of one specially for this purpose, that we should select a
substance which should  be the least susceptible of alteration  by the
iodine, or  of reacting upon this liquid.   Up to the  present  time I
have made use of syringes of pewter.
  This subject was in this  condition  in 1836 and 1837, when I pub-
lished my first observations on iodine injections.  Made trial of since
by M. A. Berard, Laugier,  Marjolin and Michon at Paris, it has pro-
cured the same results.   Moreover, a memoir  published  by M.  Du-
 jat, (France Mid., p. 2,  1836—Arch. Gen. de Med..  Janvier,  1837,)
 shows that a surgeon of Calcutta, M. Martin,  has  treated several
thousand cases of  hydrocele in this  manner, and that  out of 1000
 cases  for example,  there was  only  one return of the  disease !  The
 efficacy of this remedy,  therefore, is at  the  present day established
 beyond all doubt.  I ought to add, however, that at Hamburg, M.
 Fricke has not met with  any success from  it; but besides the fact that
 in the same town, M. Opeinheim has been no less fortunate than our-
 selves, the failures  of M. Fricke are susceptible of a  ready explana-
 tion.  M. Fricke, instead of the  cold  liquid,  made  use of  that  which
 was heated to 30° of Reaumur;  and in  place of one-third  of  the
 tincture, he employed in three of his patients, only one twenty-fourth
 part.   This  is not honestly  experimenting with  a therapeutical pro-
 cess, to make trial  of it  with  such wide  deviations '  For  myself I
 have up to the present time, (June, 1839,) made trial of it under every
 variety of form. With the tincture in its pure state or diluted one-half
 or a third or fourth part, injected  tepid or cold, with a part only or  the
 whole of it left in the cyst,  and  using it either in  recent  hydroceles
 or such as were ancient  or  small, or  of vast  dimensions, or simple,
 complicated, vaginal, hernial, acquired or congenital; in liquid  hydro-
 hematoceles, it succeeds  to  admiration;  but the best plan  is to mix it
 to the amount of one-half with water at the natural temperature and
 to leave a portion of it in the diseased sac.  Though I have decided 
HYDROCELE.
399
upon giving the preference to this formula, I nevertheless sometimes
use the tincture itself alone.  By becoming mixed with the serosity,
a portion of which also I  leave in the sac, it  produces precisely the
same effect as if it had been diluted at first with the same quantity
of water.  We have even the advantage in this way, of preventing
the escape of the iodine externally.   The alcoholic tincture of the
pharmacopeia, is  the  only one which I have  made use of up to the
present time.   In conclusion, it is demonstrated to my satisfaction at
the present day, that in the treatment of different varieties of hydro-
cele, the alcoholic tincture of iodine  in  injection, produces precisely
the same results as the vinous.
   C.  Complicated Hydrocele.—We have already seen  in treating of
the pathological anatomy of hydrocele, what  might be the  possible
complications connected with it.  If the disease exists at the same
time in both the vaginal tunics, the rule is to  perform  the operation
upon one side only at first; otherwise the inflammation might be fol-
lowed with too intense a reaction.  I cannot  perceive, however, how
there could be the slightest danger from this source, if  we made use
of the tincture of iodine, except in the event that  the hydrocele was
of very large  size.  Though it may be true that in certain cases both
tumors have been cured by operating on one only, this however is a
rare occurrence, and it is also true that in operating  on both  sides
upon the same day, the patient is restored in one half the time that he
is in performing the operations successively.
   I. When the hydrocele is composed of a turbid fluid, or one  that
is sanguinolent, or simply lactescent, and  that the walls  of the cyst
have not lost their pliancy, it is recognized by all  the different signs
above enumerated, except that of its transparency.  Provided the
liquid is not overcharged with flocculi, and that there are no concre-
tions in the cyst,  the iodine injection  will effect a cure in the same
way as in simple cases.
   II.  If, on the contrary, there should exist fibrinous or albuminous
masses, whether free or adherent; if the matter,  in place of being
serous, is of the consistence of cream or of  diluted chocolate ;  and
if the  cyst is constituted of a thick hard shell, whether the contained
matter be or be not altered, it may be affirmed  that the method by
irritating injections will in most cases be found insufficient.   In such
cases, excision is  the process generally preferred.  I have  myself
made  trial of it, and I have succeeded, but it is a painful  and serious
operation.  In some cases it  is followed by a  considerable degree
of inflammation and fever.  The suppuration does not  dry up, and
the wound will not cicatrize until after  the expiration  of one to two
months.   Since the year 1834, I have substituted instead of it  sim-
ple incisions  and a seton. With a straight bistoury,  I make by
means of a puncture an incision an  inch long, upon the  point of the
tumor where  the trochar is to be  inserted.   The liquid  escapes,
while  the finger pressed upon the cyst, detaches and expels from it
the concrete  pelotons.  If the cavity has but little extent  I stop at
this point, and encourage suppuration  by keeping the wound open
by means of  a tent.  In the  contrary  case, I incise in the  same
manner the depending point of the  sac, and insert through the two
 wounds a thin meche of linen, after the manner of a seton.   By pro- 
400
NEW ELEMENTS OF  OPERATIVE SURGERY.
 ceeding in this manner, we produce  a tumefaction and reaction,
 which reach their  highest point of intensity from  the fourth to the
 eighth day, and which afterwards decrease and allow of the foreign
 body being withdrawn, from the fifth  to  the  tenth  day.  The pa-
 tients  whom I have treated in  this manner have recovered in the
 space of from twenty to thirty days.  In one of them the seton was
 not  employed, but  I traversed the cyst with five  large incisions in
 place of two.  It is well to recollect moreover, that in this compli-
 cation the testicle and its envelopes, after the cure, remain manifestly
 larger  than upon the opposite side, whatever may be the mode of
 cure which has  been pursued.  Excision, therefore, does not appear
 to me to be indispensable, except  in those rare cases in  which  the
 liquid is surrounded with a stony, osteo-calcareous or simply creta-
 ceous shell, one instance of which has been seen by myself, another
 by M.  Mott, and three by M.  A. Cooper.   Upon the supposition
 that we  should  decide upon this  process in other cases, it would be
 more advisable, I think, to excise a fourth or fifth  of the  lardaceous
shell, rather than remove nearly the whole of it, as is recommended
by Boyer.   I have operated in this manner  on  two patients, and
with decided advantage.
  III. The  same remarks are applicable  to a hydrocele rendered
double on the same side by a complete partition in the tunica vagi-
nalis, as to  a double hydrocele,  properly so called.  That is to say,
that  we may operate  upon  both of them at the same time, or upon
the second, after having  cured  the  first.  Their proximity perhaps
would render the inflammation of the second somewhat more proba-
ble after operating  upon the first.  I consider, however,  that unless
 there are particular objections to the contrary, it would be better to
 proceed immediately to the  injection of both cysts.  In  a man 51
 years of age I  injected at first only one  of the  hydroceles.   The
 swelling and other  local  symptoms of inflammation  were  very
 strongly marked, but  it  nevertheless became  necessary to operate,
 three weeks subsequently, upon the second sac.
  IV. When the accompanying tumefaction of the testicle, or of the
 epididymis, is unattended  with pain, and inconsiderable in extent, all
 practitioners  agree that we should  pay no attention to it, and  look
 only to the  hydrocele; but, if the  tumor constituted of these parts,
 says Boyer, should be  lancinating and bosselated, the injection would
 accelerate the degenerescence.  Experience has shown me that this
 assertion is erroneous.  I have made use of vinous and  iodine injec-
 tions in many cases of hydrocele complicated with hypertrophy, tu-
 bercles of the testicle and scirrhous or encephaloid sarcocele already
 far advanced, and yet the tunica vaginalis has been obliterated with-
 out  the primary disease  having been aggravated by the  process ;
 moreover this injection, in reality, is one of the best resolvents  that
 can  be  employed in chronic engorgements of the testicle.  I have
 thus used it in patients who had the epididymis as large  as an  egg,
 slightly flattened, bosselated and painful, and  thus affected for the
 space of several years,  but who  were rapidly cured by it without
 other treatment.  I have even come to the  conclusion that in cases
 of testicular engorgements complicated with hydrocele, and where
 doubts  exist upon  the propriety of proceeding at once to castration, 
HYDROCELE.
401
it would be advisable to have recourse, before doing anything else,
to injectiDns with tincture of iodine.
  V.  The  multiplicity  of cysts  in  the tunica vaginalis, a disease
denominated hydatid hydrocele by M. Larrey, is incompatible with
the process of injections.  The  tumor, in such cases, represents  a
coarse sponge, (eponge a large mailles,) which cannot be emptied
completely by a simple puncture,  nor inflamed in every part of it to
a sufficient extent, and the septa of which might be liable to mortifi-
cation, especially from wine.   This is what took place in 1833, at La
Pitie, in an English laborer, in whom it became afterwards necessary
to remove the testicle.  In such  cases the operation by incision is
evidently preferable to all  others.  The scrotum and all its cells are
to be largely laid open by means of a convex bistoury.   Small balls
or a pliant roll of lint being inserted between the lips and down to
the bottom of the wound, compel the whole to suppurate, after which
the cavity is to be cleansed and cicatrized in  the same way as any
abscess laid open by a large incision.
   VI.  The complication of a varicocele would change in no respect
the treatment of a hydrocele, any more than would the presence of
a tumor or any lesion whatever, in the track of the inguinal canal.
   VII.  It is not altogether the same, however, with a hydrocele com-
plicated with  scrotal hernia; should  it be an enterocele, it may in
fact happen, under such circumstances, that the intestine has pro-
truded into the tunica vaginalis, and that it shows itself there  naked
through some rent or actual perforation and may encounter a species
of strangulation.   Cases of this description have  been noticed in the
practice of  Dupuytren, at the Hotel Dieu,  and in that of M. B6rard,
the elder, at the  hospital of St. Antoine.   Setting  aside the embar-
rassment which such  an arrangement must create in regard to the
diagnosis, whether in relation  to the hernia, or the strangulation, or
the hydrocele, the surgeon should not forget that by means of the
puncture he may wound the hernia  before arriving into the tunica
vaginalis, should the intestine occupy the anterior plane of the tumor;
or that he may do so after having traversed the  vaginal sac, should
the intestine be  behind ; and that if through an ancient or  recent
opening a vinous injection should come to penetrate into the hernial
sac, the most serious accidents might be thereby produced.  Before
all  else, therefore, the hernia  must be returned.   If after that, the
pressure does not cause the disappearance  of the  hydrocele, we can
proceed without danger to the irritating  injection, inasmuch as we
then have the proof that the tunica vaginalis does not  communicate
with the peritoneal cavity.  For  greater  security, however, it will
be advisable to compress the ring and to proceed in the same way as
will be  mentioned under the article Congenital Hydrocele.
  VIII. Chronic  affections of  the integuments of the  scrotum, such
as eczema, syphilitic indurations and  pustules, constitute no objection
to the operation for hydrocele, in the same way as in uncomplicated
cases.   I would make the same remark of an incipient elephantiasis,
if the effusion into the tunica vaginalis was in such cases worthy of
the slightest attention.  Should there  exist a  simple erysipelas, we
ought to wait until this has been cured.  Phlegmonous erysipelas, on
the contrary, as well  as inflammation  of the interior of the serous
   vol. in.                     51 
402
NEW ELEMENTS  OF OPERATIVE SURGERY.
 cyst, would require that we should proceed at once to multiplied and
 deep incisions.
    D. Congenital Hydrocele.—By this name is to be understood  the
 hydrocele of a  tunica vaginalis! in  which the cavity has  not  yet
 become separated  from that of  the  peritoneum.   We perceive by
 this that it can rarely be met with except in children.   Its formation
 is explained by the primary relations of the testicle with the abdomen
 on this subject, in truth, there exists a  degree of anatomical ignorance
 which ought to be corrected.   The  species of cord, in fact, which
 extends from the inguinal canal nearly as far as to the kidney, where
 the testicle is  first  found, and which, since the time of Hunter, has
 been known under the name of gubernaculum testis, is not consti-
 tuted, as is supposed, of an infundibuliform prolongation of the sub-
 cutaneous fascia.  I have seen in specimens  prepared by Thomson,
 that it was formed by  the cremaster,  and that this muscle taking on
 the form of a noose with  its convexity upwards, and in a direction
 the reverse of that which it  subsequently assumes, is perfectly adap-
 ted for depressing the testicle down to the ring.   I will remark that
 according to the same  specimens, we are compelled to admit, con-
 trary to the opinion of  Scarpa,  that the inguinal canal  is, to  say the
 least, as oblique before  as after  birth and in the adult;  that the two
 rings of this canal, so far from being situated exactly one  behind the
 other, are  also separated by quite a long track.  However this may
 be,  the testicle does not pass through the  parietes of the abdomen
 without being accompanied by a prolongation  of the  peritoneum.
 Now it is in this appendage or in the infundibulum which is produced
 by it, that congenital hydrocele takes place.  If  in depressing the
 peritoneum the  liquid should form a tumor which becomes lodged in
 front of or behind the cremaster muscle, the  hydrocele  alone might
 exist in the scrotum below the  testicle, which has been  still retained
or which remains concealed  in the inguinal canal.  In some cases the
 arrangement is entirely the  reverse;  the testicle descends first and
the  aqueous tumor is seen above it; but in  most cases the hydrocele
and  testicle present the same  relations as in ordinary hydrocele.
 This malady, which Viguerie was the first  to investigate with atten-
tion, and which is sometimes seen in new-born infants and  in the first
 months of life, is also afterwards found up to  the age of eight or ten
years, but rarely at a later period.  Though we might admit that the
 serosity could directly  reach this cavity from the abdomen. I  am
nevertheless of opinion that  it is in most cases exhaled by the tunica
 vaginalis itself.   The frictions of the scrotum  during the "progress of
 parturition, the irritations which are caused by its coming  frequently
 in  contact with the urine, and  all those different kinds  of pressure
 to which it is exposed during the first  periods of intra-uterine life,
 furnish, as it appears to me, a better explanation than the supposition
 of a diseased condition  in the  abdominal peritoneum.   Moreover it
 appears to me to be imputable  to the same causes as hydrocele in
 the adult, unless it be however that it rarely arises from an affection
 of  the testicle.   It is distinguishable  from  every other  kind, by our
 being enabled to empty the tumor by  pressure,  and  to cause  its
 liquid to return into the belly.   The age of the  patient is of itself
 sufficient to lead us to suspect its character.  As it diminishes when 
HYDROCELE.
403
the patient lies down and augments when he is standing up, there is
scarcely ever as great a degree of tension of the scrotum as in ordi-
nary hydrocele.  The communication of the cyst with the peritoneal
cavity,  moreover, is so contracted in most cases, whatever may be
the position of the testicle, that pressure does not cause the  disap-
pearance of the serosity, but makes the tumor return rather in mass
through the external ring.  The prognosis of congenital hydrocele is
at the same time less serious and more so than hydrocele in adults; less
so, because the disease disappears more  readilywithout an operation ;
more so, because the operation, should  it become necessary, would
seem to be more dangerous.  Its two  principal inconveniences are
that of interfering with the development of the testicle or in retarding
its descent, and also of exposing the child to the risk of hernia  of the
tunica vagnalis. It gets well frequently without any remedies, and by
the progress of age alone.
   Compression by  means  of a pelote  methodically sustained  upon
the ring, together with topical resolvents, will be found sufficient to
cure the patient in  a great number of cases.  I have seen two cases
of this kind cured in children of from 5 to 7 years of age by the em-
ployment of simple compresses saturated with lead water.  Unless
therefore from some particular indications to the contrary,  we  must
not be in too great a hurry to operate.  The same methods, moreover,
are applied to this as to hydrocele in general.   Incision, excision, the
tent, the seton, and  acupuncture, would  be still  more dangerous than
injection, by reason of the suppuration which they give rise to,  and
the effusion which might  ensue  into the peritoneal  cavity.   Con-
genital hydrocele,  moreover, being scarcely ever complicated with
hematocele or any  considerable degree  of thickening  in the scrotal
tunics, presents no  indication for the employment of these different
methods.   As to irritating  injections, these have been  proposed  by
Viguerie; but almost every surgeon of  the present day is decidedly
opposed to  them.   The reason they advance is  this, that during the
operation it is almost impossible, notwithstanding the most accurate
compression  made  upon the ring, completely  to prevent the wine
from penetrating into the peritoneal cavity, and that in such  cases we
should be in danger of substituting a fatal inflammation, or  peritoni-
tis, in place of an affection of a mild character.  I cannot however, in
any manner, concur with Desault in bis  fears on this point.  A young
boy operated upon by Mignot, with the vinous injection, at the hos-
pital of  Tours while I was a pupil  there, was cured without having
undergone  the slightest accident.  I have performed two similar ope
rations, and have been no less fortunate.   In the first place, it is easj
to avoid the introduction of any liquid into the  abdomen at the  mo
ment of injection; for this purpose it is  sufficient to press the thuml
into the  ring with a certain degree of force upon the pubis, while th<
assistant is  throwing up the injection.   The surgeon might even do
it himself with one  hand, while holding the canula with the  other,
should there be no assistant to whom this duty could be  assigned du-
ring the injection.   A few drops of wine, moreover, in the cavity of
the peritoneum would expose to but very trifling danger; a certain
quantity is  requisite to produce a serious inflammation.   M.  Cloquet
speaks of a patient  who had  in this manner received several ounces 
404
NEW ELEMENTS  OF OPERATIVE SURGERY.
 into the abdomen, but who nevertheless  survived.   The  swelling
 which succeeds the injection, would not allow of the few drops which
 might be remaining in  the  tunica vaginalis to  ascend into-the belly.
 As to  the  inflammation of the  cyst, it is of an  adhesive  character
 which has  but  very  little  tendency  to  extend beyond the  surfaces
 which have been in contact with the wine.   Finally, tincture of iodine,
 rendering it unnecessary to  distend the  sac, being readily absorbed,
 and causing only a moderate degree of inflammation, and but very
 little reaction, presents moreover, if I do not deceive myself, all the
 security required under such circumstances.  I am of opinion, there-
 fore, that congenital should be treated with tincture of iodine in the
 same way as ordinary hydrocele,  with  the  precaution only of clos-
 ing the inguinal canal with the thumb, during the injection, and with-
 out the necessity of afterwards keeping up this compression by means
 of a pelote, or  any bandage whatever, as some  persons  have re-
 commended.
  E. Hernial Sac.—Hydrocele  of the  hernial  sac  differs  in more
than one  respect from hydrocele of the tunica vaginalis, and  presents
itself also under various forms.  In some cases in fact, there is at the
same time both  a hydrocele and a hernia in the same sac, and in other
cases a hydrocele only in a sac which has  been  deserted by the vis-
cera.
  I.  The first case, though generally passed over in  silence, is quite
frequent.   The  contained intestine is then found  to be at the root of
the tumor, and plugs up more or less completely  either the crural or
 the inguinal ring;  the liquid surrounds it, and becomes accumulated
 below it.   It is  difficult for a hydrocele of this character  to exist
 without some symptoms of strangulation, should the hernia be formed
 by the  intestine, and difficult  therefore to confound it with a hydro-
cele, properly so called.  Should there  be, on  the contrary, any of
the epiploon, it is easy to  conceive  that  the tumor  might be  so
 arranged as to simulate in  almost every  point a  hydrocele.   A kind
 mass, of  a  certain degree  of solidity filling up  the canal and pro-
 longing itself towards the iliac fossa, and constituting the root of the
 tumor, together with the fixed position  of this last, the presence  of
 the testicle  below under the form of a small suparadded tumor, and
 also the signs of epiplocele, should any of these be present, would en-
 able us to distinguish it in a large number of cases; but it is evident
 that  we  would  be liable to be deceived in some others.   Suppos-
 ing, however, that  the disease should have  been recognized, and that
 the hernia should not have caused  in itself .any accident, what ought
 we to do ?  I do not hesitate to say that it would be advisable to apply
 to it, as I have in three  instances done with success, the treatment for
 congenital  hydrocele.   Should the  hernia occasion ever so  slight a
 disturbance, it would be better, I think, to  lay  open the sac  and to
 proceed as  in strangulated hernia.
   II. The second variety is better  known  than the preceding.  Le
 Dran had already spoken of it, and the case which he relates possesses
 also this remarkable feature, that  there was  at  the  same  time  an
 encysted hydrocele of the  cord, together with hydrocele in the tunica
 vaginalis, and  an  hydrocele in a hernial sac.   Its formation, more-
 over,  is  easily   explained:  a reduced hernia leaves an empty sac, 
HYDROCELE.
405
which may be filled with serum on the following day, or closed up
above at  the  expiration of a few years,  if a hernial bandage has
been  properly maintained.   This sac  being only a simple  serous
cyst then, scarcely differs  any longer from the tunica  vaginalis.
Several  pouches  may in this  manner be successively established
from  the  reproduction  of a hernia at different  intervals  of time,
more or less  distant.   In a patient operated  upon by  M. Belmas
and myself, in 1831, there was one of these cysts of the diameter of
a small egg, together with  a small sac of  much less extent, and at
the same time a large sized hernia.   This variety of hydrocele, while
presenting, or being capable of assuming  a certain resemblance to
varicocele,  might  be still more  easily confounded  with hydrocele
of the cord, or should the  cyst  be large, with a hydrocele  of the
tunica vaginalis.   The pre-existence of a  hernia, however, together
with  the  development of the tumor  from above downwards, and the
isolation of the  testicle and its position below  the sac, constitute
so many characters which might lead  to a correct opinion.  I  do not
consider that there would  be  the least danger in operating  for it,
in the same way as for  simple  hydrocele,  provided we took care
to close the ring during the injection into the cyst.  Facts  of this
description, collected in my  department, have been published in seve-
ral journals, (Presse Med.,  1837—Bull,  de Therap., 1838, 1839—
Gaz.  des Hopit.,  1839, p.  106.)  Should the possibility of a commu-
nication  with the peritoneal cavity,  or the  multiplication of sacs  in-
spire  some  apprehensions, incision would be the  best remedy; the
cyst  should  afterwards  be filled with small  balls of  soft lint, in
order to excite suppuration in it, and  to  cicatrize it after the man-
ner of an abscess.
  F.  Hydrocele  of the Cord.—The  spermatic  cord  being consti-
tuted of a certain number of lamellae, united together by loose cellular
tissue, presents one of the  most favorable anatomical arrangements
possible for the  formation  of  cysts and  different  descriptions  of
infiltration:  consequently  there have been  long noticed in this part
the two varieties  of hydrocele, viz., that by infiltration and that from
effusion,  or  what is called encysted  hydrocele.
  I.  Infiltration,  whether  sanguineous, purulent, or  serous, and
oedema, whether idiopathic or symptomatic, may well be the source
of a hydrocele from infiltration of the cord, but do not constitute this
form  of disease.   This disease, which is essentially local and chronic,
is made up of a more or less considerable  number of small cysts or
cells  filled with  serosity,  occupying sometimes the entire length of
the cord from the epididymis to the iliac fossa, and sometimes  a part
only of this organ, either in the direction of the scrotum or that of
the inguinal canal.  Its causes are  but little known, and the  exam-
ples of it are quite rare.  The tumor presents  itself under the form
of a bosselated soft cord, without any pain or cakiness, (empatement,)
or change in  the  color of the skin, of the  diameter of an inch, or a
little  more,  or somewhat less, and which  is arrested by a sort  of
strangulation  at the root of the testicle or above it,  or  occasionally
prolonged to  a considerable distance  into  the inguinal canal.   This
tumor, constituting a  portion of the body of the cord, being incapable
of being either depressed or raised  up  without the testicle, and 
406
NEW ELEMENTS  OF OPERATIVE SURGERY.
 possessing a very great  degree of mobility, and existing indepen-
 dently of the scrotum, properly so called, will occasion, when pressed
 upon in a certain manner, a pain analogous to that which is produced
 by pressure on the testicle.  Hydrocele, by infiltration, occasions still
 less annoyance to the patient than hydrocele of  the tunica vaginalis.
 As it rarely acquires a large volume, those who are  affected with it
 are frequently unconscious of its existence during the space of seve-
 ral years.  When, however, it exceeds the dimensions of an inch, and
 occupies the inguinal canal, the solid walls which it is obliged to dis-
 tend, ultimately render its presence annoying and sometimes quite
 painful.   It  may, moreover, whatever be its position and size, react
 on the vas deferens and fatigue the testicle.  Finally, its indefinite
 increase, or any other  circumstance, may cause it  to inflame  and
 transform it in  reality  into  a serious  disease.  Provided it  occa-
 sions ever so little disturbance  therefore, or has attained a consider-
 able volume, it is  advisable to relieve  the patient of his  difficulty.
 Though it may be true that hydrocele of the cord by  infiltration may
 disappear without  an operation,  this result at least  must be a rare
occurrence, for I know no examples of it.   I will add, that the pallia-
tive cure is not applicable to this disease.   Either we must do nothing
or undertake an operation calculated to effect  a radical  cure.   In
these cases, caustics, excision, the  seton, a tent, and even injection
itself, should be proscribed as dangerous or of no utility.  By trav-
 ersing the whole tumor in the direction of its length with a  simple
 thread, as I have done in one instance, we should  not succeed  until
 after having transformed it into an abscess, which it would  almost
 always be found necessary to  open largely at a subsequent  period;
 incision, in fact, is almost the only remedy for this disease.   In the in-
 guinal canal, this operation would be very dangerous, and we should
 not decide upon it unless the hydrocele should have  actually caused
 serious accidents.  Between the ring and  the  testicle, also, it is  not
 without its inconveniences, since  it  incurs  the risk of wounding  the
 vas deferens, as well as the spermatic veins and arteries.  It is  im-
 portant also, in order to ensure success, that the  infiltrated cylinder
 should be laid open throughout its whole extent.  Whatever  be the
 method chosen, it is an  operation more serious than that for  vaginal
 hydrocele, and  one which  it would be advisable not to perform unless
 we are, so to speak, forced to this step by the  annoyance which  the
 malady produces.   The patient is to be laid upon his  back, as in the
 operation for hernia.  The surgeon with  his left hand grasps  and
 gives tension and  prominence  to the tumor in front, while with  a
 straight or convex bistoury in his  right hand, he divides, layer by
 layer, all its envelopes.  Down to the cremaster muscle there is no-
 thing to fear, but before going farther, he should satisfy himself as to
 the actual position  of the  epididymis, because it  indicates in what
 direction he is to look for the vas deferens.   This last is usually be-
 hind, accompanied with the spermatic artery, and  on the other wall
 of the hydrocele we meet  with the veins.  Nevertheless, it would be
 better to penetrate at that point than near  the artery, unless  it were
 found impracticable to go  between those two descriptions of  organs.
 After having laid open and emptied, by making pressure, all thelnfil-
 trated cells, and after having  checked the hemorrhage, if any  has 
HYDROCELE.                        4Q7
taken place, the whole wound is to be  filled up with a pledget or
small balls  of lint;  the perforated linen,  plumasseaux,  some  com-
presses, and a suspensory, are applied over these, and the dressings are
afterwards conducted in the same manner, as has been said in speak-
ing of the method by incision in general.   As soon as the suppura-
tion is established over the entire surface of the  cavity, some advan-
tage will  be derived by favoring the approximation of the lips of the
wound by means of adhesive plasters.  The cure  will be thus obtained
in fifteen  days or a month,  rarely sooner, but sometimes later.
   II. Encysted Hydrocele.—Encysted hydrocele of the cord, though
sometimes a  primary disease, quite frequently also succeeds to the
foregoing variety, which latter constitutes, so to speak, only its first
stage.  It may be easily  conceived, in  fact,  that in the  course  of
time one or  more of the  cells of the infiltrated cord may become
enlarged  and more distended "than the others, and  thereby soon con-
stitute actual  cysts that will engage all our attention.  Encysted hy-
drocele of the cord, moreover, is sometimes simple and sometimes
multiple.   Its form is usually globular or  ovoid, and  its volume
varies from that of a small nut to that of the fist; but in general it is
of the size of that of a large  nut or a pullet's egg.   Both during its
development, and in its condition as  a  tumor, it presents  the same
characters as vaginal  hydrocele, but  its differential  diagnosis is  at-
tended with some particular difficulties:  it is not either with varico-
cele, hernia, sarcocele, or hematocele, that  it can be confounded, but
it may be with a supernumerary testicle.   Scarpa gives an account
of a mistake of this kind, and in 1836 I saw at La Charite one of the
most remarkable facts under this point of view.  In a man about 30
years of  age, the  volume,  form, density, and mobility of the  cyst,
were so precisely similar  to  what is seen in the testicle, that after
having purposely changed the position of the two masses in presence
of assistants, I was enabled to deceive several very experienced sur-
geons.  In this case  the abnormal sac had  existed  from infancy, and
the patient considered  that he had three testicles.   In examining it
more closely,  however, it was soon perceived that there was no epi-
didymis under the cyst, and that the cord which occupied its place
behind was  prolonged as far down  as  to  the lower tumor.  Com-
pression  also  served to distinguish the two tumors, since it caused
scarcely any pain in  one, while in the other it produced the sensation
so characteristic from pressure on the testicle.  In associating with
these particular signs, the transparency of the cyst and the opacity
of the seminal gland, we had and others will have, in such cases as
I  have proved in two instances, in 1837 and 1838, sufficient indica-
tions to remove all doubts,  should the other characters of the tumor
have left  any uncertainty in the mind of the surgeon.  It is never-
theless true  that the  diagnosis of encysted hydrocele of the cord is
sometimes sufficiently difficult.  Whether it be  monolocular or mul-
tilocular  in fact, how, when the tumor or  tumors are found in the
neighborhood  of the inguinal canal, caa we distinguish this disease
from cysts formed  by ancient hernial sacs 1  If, as I consider, this
disease is  quite frequently established  in a remaining  free portion of
the ancient peritoneal canal, and if in  growing large it  inclines in
the direction  towards  the  testicle, who  is there that would net be 
408
NEW ELEMENTS OF OPERATIVE SURGERY.
 liable to confound it with a hydrocele of the tunica vaginalis ?  How
 moreover can we be certain "that the pouch or small pouches are not
 caused by abnormal or morbid adhesions of the natural serous en-
 velope of the testicle, as in one of the cases which I have above re-
 lated ?  Fortunate will it be if these embarrassments in the diagnosis
 have no bearing either upon the prognosis or treatment of the dis-
 ease, for it may be absolutely impossible to unravel them.  Encysted
 hydrocele of the cord is scarcely ever seen under an acute form;  it
 usually progresses, on the contrary, with an extreme degree of tar-
 diness. As it rarely exceeds the size of a large egg, it scarcely pro-
 duces  any reaction  upon the testicle, while it  occasions  but very
 little annoyance to the  patient.   I have also  met  with numbers of
 patients who have never expressed the least desire to make trial of
 any remedy for their relief.   All that I have  said  upon the subject
 of the treatment of hydrocele of the tunica  vaginalis, is applicable
also to this disease.   Modern surgeons, who have  asserted that the
tumor was situated too  deep, surrounded with some of the elements
which  make  up the  cord, in  too near neighborhood to the perito-
neum, &.c, have overlooked  the  fact that these circumstances would
render the incision or excision which they recommend much more
dangerous  still than  injections, which they proscribe.  Apart from
the testicle the relations are  in reality the same here as in vaginal
hydrocele  ; and should  the cyst have ever so little volume, it would
still be the method of injections which would  be best adapted to it.
I have operated upon ten patients in this manner, and have never
procured results more complete or more simple.  I would therefore
recommend that we should never proceed  in any other  manner, and
that we should not employ incision, or the  seton, which is still pre-
ferred  by M. Brodie, (Arch. Gen. de Mid., t. XIV., p. 77,) nor ex-
cision,  unless there should be several cysts, or that the tumor by be-
ing prolonged  into the  inguinal canal, should  lead to  the  suspicion
that there was a communication with the cavity of the peritoneum.

                 §  II.—Hydrocele in  Women.

  Scarcely any attention  has been paid to  hydrocele in women until
during the last half century.  A passage in Aetius leads to the suppo-
sition that Aspasius had noticed it.   Pare mentions a  young girl, six
to seven years of age, who was affected  with  it; Desault and Lalle-
ment also have each met with an example ; but it is in Italy especially,
in these latter times, that it has been the subject of special" researches.
Paktta first, M. Sacchi  afterwards,  and  more  recently  still M.
Regnoli, have gone more minutely into the details of this matter than
any person had ever done before them.   The  researches  of these
observers  would go  to confirm  the  opinion, which  was  already
ancient, of those who consider that in women  hydrocele has its seat
in  a peritoneal prolongation known under the  name of the ligament
of Nuck,  and which, making  its exit through the inguinal canal,
becomes the counterpart  to the tunica vaginalis.   M. Regnoli con-
siders also that there  may be both a diffused and an encysted hydro-
cele of the round ligament; he likewise speaks of a hydrocele in an
ancient hernial sac, and facts are brought forward in support of these 
HYDROCELE.
409
opinions.  An attentive examination of the principal subdivisions of this
question lias long since convinced me that it stood in need of farther
investigations.  I have  various reasons for believing,  for example,
that several, if not  all the tumors described up to the  present time
under the name of  hydrocele in women, consisted of nothing  more
than  serous, sero-sanguineous  or sero-mucous  cysts  of the  labia
majora or mons veneris.  In the first place, the round ligament of the
uterus does not, as I had supposed with all  anatomists,  lose itself
ultimately  in the apex  of the vulva.  I have proved,  as Thomson
has, that this cord  terminates on the pubis and  in the posterior wall
of the inguinal canal.  It follows from this, that the peritoneum is not
prolonged outside of the belly in the form of a cul de sac as in man,
and thus we cannot understand how a hydrocele, similar to that of
the tunica vaginalis, can take place in woman.  Seeking  afterwards
in the facts published the proof of the results they have deduced from
them, I have found  none of them conclusive on this point.  The cyst
was between the ring  and  the labium majus in the cases of Pare,
Desault and Lallement,  and in two of those of Paletta.   The labium
majus itself was the seat of the cyst in many other cases.  The com-
munication with the  peritoneum  was  scarcely established satisfac-
torily except in a single instance, and even in that it is  possible that
this communication may have been made by  the surgeon himself at
the moment of the  operation.   As to the examples of  hydrocele of
the round ligament, whether diffused or encysted, there is no reason
why we should not consider them as facts, with this proviso, how-
ever, that it would  be erroneous to compare  them with those which
have been encountered in the spermatic cord  in man.   I will add in
the third place, that having seen four women affected with the disease ^
in question, [ ascertained in  them, at least to my satisfaction,  that
the cases were those of accidental cysts,  and  not effusions  into a
primary peritoneal  sac.   These women, who were  all  of a  certain
age  except one,  who  was  only twenty,  had  severally had  these
tumors  for the space of one, three, eight  and  eleven  years.  The
cyst was of the size of an egg, or somewhat less.  In one it was seen
in the  mons veneris in  front of the ring, but in the others it occu-
pied the upper half  of the labium majus.  Two  of  these hydroceles
were filled with a  thin  and glairy matter like that of  the white of
an egg;  in the two  others it consisted of a serosity of a slightly rose
colored tint.  The sac, which was smooth like a mucous or synovial
bursa in its interior, had walls of the thickness of three to six  lines,
though quite pliant.   These tumors certainly had no relation nor any
continuous  connection, at least with the  peritoneum  or the  round
ligament.   Might not such cysts be the consequence of former effu-
sions of blood produced  by frictions or contusions? What I have
seen so often underneath the skin and in serous  cavities in general,
would authorize me to make this  suggestion,  but would not  be suf-
ficient, I confess, to  establish its truth.
  However this may be, cysts known under the name  of hydrocele
in women, are movable tumors, without pain and  globular, elastic
and fluctuating, with  walls which  are  generally quite  thick, and in
which it is  rarely possible to  discover any transparency, having their
seat sometimes in the middle portion, sometimes at the upper part of
   vol. in.                     52 
410          NEW  ELEMENTS OF OPERATIVE SURGERY.

the labium  majus, in other cases in front of the ring, or even in the
inguinal canal.   The development, progress  and consequences  of
such tumors are the same as those of encysted hydrocele of the cord
in man.  Their position, however, in the midst of a cellulo-adipose
tissue, which is sometimes considerably abundant,  and the friction
which is made upon them during coition or parturition,  render  both
their  diagnosis more difficult and their prognosis more serious. It may,
in fact, be conceived that in the course of time a tumor of this  kind
might become inflamed and transformed  into an abscess, or acquire
a considerable degree of  size and weight.   The treatment, however,
is the same  as in that of encysted hydrocele of the cord:  caustics,
the seton, tent, acupuncture, incision, excision and the different kinds
of injections, therefore, could be applied to the disease.  Whatever
may be the  method employed,  there is  this thing to be remarked,
that the operation for hydrocele in women is scarcely  accompanied
with any danger:  there are no testicles or spermatic cord to  be
respected; no infiltration to be  apprehended during the injection ; in
fact, scarcely any of those results which might create alarm in ope-
rating  upon  man.   The important point, therefore,  is to choose the
best of these different processes : and in this  respect there can  be
no doubt that injection, incision and excision are much preferable to
the other methods.  If the cyst  is thin, supple and filled  with serosity
only, and if  it is at the same time of considerable size, the treatment
by injections is  better than  any other.   When the  tumor  does not
exceed the size of a small  egg, and its walls are not  too  much in-
durated, incision is preferable.   Excision  would hav*e more advan-
tages, on the contrary, if the case in question was one  of hydrocele
with lardaceous walls filled with thick or flocculent matter,  or in
part liquid and  in part concrete.   In whatever way we proceed, I
lay it down  as a rule, to  direct the instrument upon the cutaneous
wall  of the tumor, even though  it might be possible to attack it upon
its mucous or vaginal side :  this is a rule which I follow for all col-
lections in the vulva, whether they be sanguineous,  purulent, serous
or otherwise, and one which I have adopted because the vulval and
vaginal humidities are a real impediment to the cleansing and speedy
cicatrization of suppurating cavities in this region.   The cyst, more-
over,  should be laid open throughout its entire length or a large por-
tion of it excised, for there is no necessity in these cases of preserv-
ing its parietes.   I would add, that if the tumor  should be  very
movable under  the  skin, we might advantageously substitute extirpa-
tion to excision  or incision, and that unless some very particular objec-
tion should exist, cysts developed in the interior of the inguinal canal
should be treated by incision  only.  The possibility of pushing the
irritating liquid  into the abdomen, and of wounding  the peritoneum
or some important vessels, as the epigastric artery for  example, would
not justify the employment of injection or excision in such cases, ex-
cept  under  peculiar circumstances, and would be almost  always a
sufficient reason for restraining the  hand of the surgeon.
   [Iodine Injections in Hydrocele, fyc—In an animated discussion
which took  place in the Royal  Academy of Medicine of Paris, Sep-
tember 9, 1845, and which  continued during several subsequent sit-
tings,  (see Arch. Gen. de Med., January, 1846, 4e ser., t. X.. pp. 103, 
HYDROCELE.
411
104, and  Ibid., February, 1846, p. 226-234,) on  the  occasion  of a
report of our author, M.  Velpeau, upon a memoir of Dr. J. Roux on
iodine injections, employed successfully by the latter in a case  of
scapulo-humeral hydarthrosis, we perceive that the professor of La
Charite still strenuously  adheres to this practice, which has now,
chiefly through his exertions and the successful  results he has ob-
tained from it, become  generalized among the  surgeons of most
countries.  M. Velpeau  insists, especially, on the superior advan-
tages of iodine injections in hydropsies of shut cavities, and also in
hydarthrosies  and  hydroceles.  In the debate which succeeded to M.
Velpeau's report, Professor Roux  stated that he considered vinous
injections had  been unjustly censured: that he had employed  them
in no less than fifteen hundred cases, of which number four only had
terminated fatally.  Wine  he thinks full as good  as  iodine, and
besides it is far cheaper, and also accessible to every one.  In hydar-
throsies he prefers  the ordinary treatment, and thinks puncture should
not be resorted to but as an extreme measure, as it is by no means
without danger.   M. Blandin coincided  with Professor  Roux, and
was surprised  that M. Velpeau had  not  mentioned in his treatment
of effusions into the joints, the importance of strong mercurial unc-
tions, together with immobility, and compression by means of -the
starch bandage, (appareil inamovible.)  He does not reject puncture,
but dreads the admission of air  into the articular  cavity.   In hydro-
cele he considers iodine more feeble  and  less certain than vinous in-
jections, and, in support of this, gives cases where the wine succeeded
in effecting a* perfect  cure after the iodine, administered according
to M. Velpeau's directions, had wholly failed.  M. Gerdy concurred
in the main with  Professor  Roux and M.  Blandin, and seemed to
doubt the alleged  successes of iodine in  hydrocele.  His argument,
however,  against  iodine  because it  acts  as a poison, in experiments
on dogs, is at  best but one of a feeble collateral value.  He is to be
applauded, however, as we think,  for  his  adhesion to  the  more
rational doctrines  now prevailing  in favor of conservative surgery,
so far as relates  to a rash resort to  puncture of close and articular
cavities, the peritoneum, &c.   M.  Jobert zealously  supported the
principles laid down by M. Velpeau, founded upon the latter's bril-
liant and  repeated cures by iodine, and which  cases M. Velpeau
again reproduced in opposition to the assertions of MM. Roux,  Blan-
din and Gerdy.   M. Jobert does not deny that the  disease  may
sometimes return after iodine injections, but much less frequently, he
asserts,  than after  the vinous.   Out of seventy  cases  of hydrocele
treated  by iodine the disease returned in three only.  Again, iodine
even  when infiltrated  into the tissues of the scrotum,  does not, in
general, occasion  gangrene; and,  even when it  does, it  is limited
and  trivial  in importance compared with  that caused  by  wine.
And lastly, he asserts that poisoning need not be apprehended, as he
has injected two hundred to two hundred and fifty grammes of pure
tincture of iodine into cold abscesses without any accident occurring.
  M. Auguste Berard, adopting the same views, stated that in 250 to
300 cases of hydrocele treated by him with iodine, there  were three
only in  which  the  disease returned.  In  two cases of hydropsy  of
the knee-joint, it produced no effect, and amputation had to be resort- 
412
NEW ELEMENTS  OF OPERATIVE SURGERY.
 ed to.  In no case did he find any poisoning.  M. Laugier also con-
 curred in these opinions, and considered iodine injections full as effi-
 cacious, and also less painful than those of wine, and much more sim-
 ple in their manual. He suggested however, that the efficacy of iodine
 injections might probably be solely ascribed to the alcohol of the
 tincture.
   In conclusion, M. Velpeau eloquently defended his positions.   The
 dangers of vinous injections, and the well known resolvent properties
 of iodine, and the usual enlargement of the testicle, which accompa-
 nies  hydrocele, were his chief motives for the new practice.  En-
 couraged by his remarkable successes, he tested the iodine in cases
 of liquid hematocele, cysts of the spermatic cord, neck, limbs, and ova-
 rium,  and in cold abscesses, mucous bursce, and hydarthrosies.   He
 found the inflammation thereby produced, in such close cavities, was
 not only limited, and rarely diffuse, but that it possessed also the effi-
 cacy of entirely destroying the disease by obliteration of the cavity,
 or a specific modification of its walls.   He pointed out with minute
 directions the manual of the process, and the necessity of modifying
it according to the disease, and the greater or less irritability of the
patient, supporting all his statements on remarkable examples of cures
of unquestionable authenticity.   He then proceeded to a thorough
examination of the pretensions of vinous injections, and demonstrated
with his ready erudition and his felicitous tact, in applying it to the
 elucidation of truth, that vinous injections, however lauded to-day,
were deemed highly dangerous by  a  crowd of authors  anterior to
this epoch, as he showed  by his  citations from a greaj  number of
them, and among others, Boyer.   He also established, that a majori-
ty of modern  authors are clearly in favor of iodine, and took the lib-
 erty of explaining the failures mentioned, by ascribing these reverses
 to the surgeons themselves, and  not  to the  iodine,  and that in the
 cases of MM. Chassaignac and Reihet, the injections were complica-
 ted with incisions, and  therefore that  they were  not fair data to
 reason upon.
   The editor of the Archives regrets that an exact comparative sta-
 tistical table of the relative results of the two processes was not pro-
 duced.  He must,  however, be sensible  of the impossibility of pro-
 curing such details with accuracy, from those whose minds are  al-
 ready biased by preconceived predilections for either one or the other
 mode of treatment.
   In respect to the employment of iodine injections  for the purpose
 of obliterating hernial sacs, it is to be  remarked  that the subject ap-
 pears to have been touched upon  in the  debate, but disconnected as
 far as we can perceive with any facts  as yet obtained in Europe, on
 this new practice.   We have alluded to it in our first volume, and also
 above in this, and believe  the idea is,, in  its application at least, alto-
 gether due to our own  countrymen.    Since our first volume was is-
 sued from the press, nothing has come to  our knowledge to show that
 any further advances have been made in this mode of curing hernia.
   M. Guibourt, at the sitting of the  Royal Academy of Medicine of
 Paris, Jan. 13,  1846, (Journ. des Conn. Med-Chir., Fevrier 1, 1846,
 p. 72,) remarked that the tincture of iodine produces different effects
 according as it is fresh  or old.  The fresh or recent  tincture is more 
HEMATOCELE
413
irritating, from the iodine not being completely dissolved, but remain-
ing partially free, in a state of suspension in the alcoholic vehicle, on
which account it is deposited in a natural state (en nature) on the
tissues, and acts upon them with all the intensity that pure iodine is
known to do.   When the tincture, on the contrary, is old, the iodine
is not precipitated, in consequence of the new combinations brought
about by the prolonged action of the air; it changes, however, more
or less, but its effect becomes less and less irritating.  M. Velpeau
had, up to  Jan. 1,  1846, (see Journ. des  Conn. Med.-Chir., Paris,
Janvier 1, 1846, pp. 10—12,) used iodine injections with entire suc-
cess in twelve to fifteen cases of hydarthrosis of the knee-joint, only
one of which was followed by anchylosis.  To avoid this, a certain
degree of movement is exercised  upon the  joint immediately after
the injection, and these movements are to be continued until the func-
tions of the knee are re-established.
  By the  Compte Rendu of the surgical clinique of Prof. Bouisson of
Montpellier, for January, 1846, we are gratified in perceiving (see
M. H. Rodrigue in Journ.  des Conn. Med-Chir. de Paris, Mars  1,
1846, No. III., p. 116,) that the favorite iodine injections of our author,
M. Velpeau, in hydrocele, are  in  great esteem at  that celebrated
southern  university of France.   They  are adopted  by MM. Serre
and Lallemand in lieu of the vinous, because they rarely find them
followed  by a return of  the disease, and are also  less painful, and
never produce poisoning, (accidents toxiques.)  After the vinous in-
jections, gangrene, according to M. Rodrigue, (Ibid., loc. cit.) is a
very common occurrence ; but as yet we have only one well authen-
ticated accident of this kind from iodine, viz. that related by M. Ca-
rion, 1844.  At the  hospital of St. Eloi, Montpellier, the solution em-
ployed is  composed of equal parts of iodine and water.  It appears
that as long since  as  March 20,  1841, an injection of tincture  of
iodine (32 grammes to 4 of iodure  of potash and 150 of water,) was
used with success, after tapping, in a case of ascites, by M. Dieula-
foy, (see Journ. des Conn. Med.-Chir. de Paris, Mars 1,1846, p. 125,
&c.) of Toulouse.   M. Dieulafoy, according to M. Velpeau, (Journ.
cit., Fevrier 1, 1846, p. 70,) has a second time used iodine injections
into the peritoneal cavity with success in another case of ascites.
  Spermatozoa, or spermatic animalcules, have been noticed in the
liquid of hydroceles, by M. Velpeau, (Arch. Gen. de Med.  de Paris,
4e ser., t.  III., pp. 402, 403,) and soon afterwards also by Mr. E. A.
Lloyd, (Medico-Chirurgical Review, Oct., 1843.)   T.]

                   Article  II.—Hematocele.

  Hematocele is a disease almost the entire history of which has yet to
be written.  A great number of observations ranged  under cases of
hydrocele belong to this.   Thus, in all those  cases where it is said
that the matter contained in the cyst was of a red, brown or ruddy
color, and of a consistence resembling honey, boiled meat, chocolate
or lees of wine, we may be certain that the case in question was one
of hematocele.  The same  remark is applicable to those  cases in
which  the liquid, though in reality fluid and simply of a  yellowish
color, has been found in small quantity and contained in a thick and 
414
NEW ELEMENTS  OF OPERATIVE SURGERY.
as it were fibro-cartilaginous  vaginal shell, formed of friable plates
superimposed upon each other.
   The case of the Counsellor  of Payerne, mentioned by F. de Hil-
den, and whose death was caused  by an operation  performed by a
charlatan, two cases also  of Saviard, (p. 123, 125,)  that mentioned
by Scarpa, and the two facts upon  which M. Raybard justifies him-
self  in establishing a new operative process, and also the three cases
of Dupuytren, all come under this description.   By the fact alone,
therefore, that a tumor of the scrotum, having the same form, vol-
ume, regularity, and insensibility, as a hydrocele,  is found to have  a
much greater degree of weight, an  absolute want of all transparency,
and a consistence of a fibrous character, we are authorized to affirm,
if the tumor is disconnected with the  testicle, that it is  an  hemato-
cele, either in a simple or  perverted state.  All doubts will  be re-
moved as soon as it shall have  been ascertained by a careful explo-
ration, that the testicle is  more  or  less flattened, and firmly seated
upon some one point of the periphery of the cyst.  Only that it is
not to be forgotten that in these cases, as in hydrocele, this organ,
which is usually situated behind and on the inner  side, is sometimes
placed in front, and upon the outside or  below.   If we add  to this,
that hydrocele may be transformed into  hematocele, or hematocele
into  hydrocele, we  shall  be in possession, as  I  consider, of all the
light required to  avoid any mistake in cases of this description. The
treatment of hematocele, considered  under  this point of view, does
not appear to me to "have  been hitherto  properly understood.  The
disease having been sometimes  confounded with hydrocele,  and in
other cases with  the tumors of the testicle, has always been  attacked
either by one of the operations above described  or by extirpation.
The facts which I have noticed enable me, at the present day, to as-
sert  that the  diagnosis and treatment of hematocele, whether recent
or ancient, may be established  and carried out with as much facility
as those of hydrocele  or sarcocele.

                              § I.

   In the beginning, all effusion of blood infiltrated into the tissues of
the scrotal tunics, may, by means of topical resolvents, be  resorbed
and  disappear without the necessity of an  operation.  A deposition
in the tunica vaginalis ought also to be subjected  to the same treat-
ment, and the operation ought not to be resorted to in these cases, un-
less  after the lapse of a month or six weeks there  should be  no evi-
dence of any tendency to resolution.

                             § II.

   The operation, which would be advisable under such circumstan-
 ces, is tne same  as for an ancient hematocele.  We may then choose
 between several processes.
   A. The excision of the entire  thickened shell was the method em-
 ployed by Boyer and his  school, after the  rules  which I  have  laid
 down above.  Dupuytren, who  also  made use  of this method, re-
 moved only the  free portion of the tunica vaginalis, without making 
HEMATOCELE.                        415
it a point of necessity, like Boyer, to dissect this shell as far down as
to its connections with the testicle.   These two  modes of operation,
which I have  myself occasionally employed, are  painful, laborious,
and dangerous.  It is frequently difficult to  respect  all the portions
of the spermatic cord, and the vas deferens  has in  more than  one in-
stance been included in the excisions.  The  enormous wound which
it is  found  necessary to establish,  and the abundant  suppuration
which necessarily  ensues,  expose to the  risk of consequences infi-
nitely more dangerous than those of  castration.
  B.  Some surgeons also have considered, that it would be more ad-
visable to recur at once to this last operation, than to subject  the pa-
tient to a dissection, the only benefit from which would be to preserve
a testicle, which in fact is too profoundly altered not to have  lost its
principal functions.  Instances  of castration performed under  such
circumstances,  are still  met with quite frequently in our days.  M.
Piussan, (These, No. 215, Paris, 1825,) mentions one from the prac-
tice of M. Roux.  I am also  induced to believe that the alledged en-
cephaloid sarcocele, mentioned by M. Sornay, (Ibid., No. 86, Paris,
1837,) and which was extirpated at  the Val de Grace, was no othei
than an hematocele.  I have  myself  adopted this method in two in-
stances in 1832 and 1833, even though I  had ascertained with cer-
tainty that the tumor was disconnected with anything of a cancerous
character.   In  a case  of  large sized  and  ancient  hematocele, M.
Voisin, (Gaz. Mid., 1839, p. 81,)  having emptied the sac by an injec-
tion, considered it proper afterwards to remove  the testicle.   At the
present time, however, it is requisite that this practice should undergo
a reformation on this  point.  Hematocele requires neither excision
of the tunica vaginalis, nor extirpation of the testicle. I have  treated
and cured a great number of patients with this disease by either one
of the two following operations, and  which are the only ones I have
employed since the year 1834, whatever may have been the  degree
of thickening or induration of the tunica vaginalis.
  C.  Injection.—I begin with a  puncture by means of the trochar.
If the effused matter is sufficiently liquid to escape  freely through the
canula, I empty the sac of it as perfectly as possible, in the same man-
ner as in the hydrocele.   Even  though  there  should remain some
flocculi or fibrinous clots, I throw up an  injection of diluted tincture
of iodine precisely in the same way as if it was a case of hydrocele.
A patient whom I treated in  this manner with  M.  Rivaille, and in
whom the tunica vaginalis  contained about a tumbler of fluid blood
of the consistence of wine lees,  experienced  neither pain nor any
evident fever;  resolution commenced on the sixth  day, and the cure
was  so complete before the end of the  month, that the operation
and its consequences in the  aggregate were all exactly similar to
what  takes place in the most simple form of hydrocele.   I will re-
mark  that an analogous case was noticed by M. Gerard,  who com-
municated the details  of it to the Royal Academy of Medicine in
1837.  The important point in these cases is to lay open and to empty
the sanguinolent collection by means of  a  trochar, and not by the
bistoury.  If the injection should be made through an incision, it is
probable that the cyst would  enter into suppuration, and that the ope« 
416
NEW ELEMENTS OF  OPERATIVE SURGERY.
 ration,  besides being less effectual, would be  attended  with conse-
 quences much more serious.
   D. Incision.—When  the tunica vaginalis  is filled chiefly  with
 fibrinous clots, or concrete  matter, and it is impossible in fact to empty
 it by the canula of the trochar, it is no longer allowable to have re-
 course to irritating injections.  In such cases, the remedy should be
 that of the multiple incisions. The patient is placed in the same way
 as in the operation for hernia.  The surgeon being on the right side,
 grasps and raises up the diseased  side of the scrotum, and stretches
 the integuments while embracing the whole mass below, with his left
 hand.  A straight bistoury  inserted in place of the canula of. the tro-
 char, or along this  canula if it has a groove, serves to lay open the
 acrotum to the extent  of an  inch, in the same way as  in opening an
 abscess, from within outwards.  The forefinger being introduced into
 *he sac through this opening, detaches the concretions from it, and
 enables us to empty it completely.   The finger afterwards serves as
 i guide for making at the depending or thinnest point on the hematic
 ".avity, an incision  similar to the first, and which  should  be effected
 from the  interior to the exterior, or vice versa.  Having abundantly
washed out the entire  vaginal cavity by a copious injection of water,
nothing more remains  to terminate the operation, than to pass througn
the two incisions a flexible  probe  threaded with  a long meche of
linen, embued with cerate, and the two extremities of which are to
 be tied into a knot, and left  there as a seton during the space of four
or five days.  The whole is then dressed with  emollient  cataplasms,
and supported by a suitable suspensory.   After having moved about
the seton in the usual manner, until a proper degree of inflammation
has been established in the sac, that is to  say, morning and evening,
for about the space of a week, it is then withdrawn from the tumor.
It is then advantageous to dress it with emollient cataplasms, so long
as the inflammatory period  lasts, and until the suppuration  has as-
 sumed a  healthy appearance, or has considerably diminished in quan-
 tity.
  E.  In  conclusion,  the. operation for hematocele  should in every
 respect be the same as that  for abscesses of considerable  dimensions
 with  attenuation of the skin, or that for chronic purulent cysts.  If
 any  points upon the  cyst should  be found to  have become attenu-
 ated during  the course of the treatment, or if any of  the matters
 had  become stagnant in certain  culs de  sac, it would be advisable
 to make additional incisions.  I have treated  14 or 15 patients by
 this process, and all of them were cured ; and the greater portion
 in the space of from three to six weeks.   In one only, the last
 wound did  not close  up until at the end of  two  months.  There
 was   another, however,  who died ;  but in  him  the  hematocele,
 which occupied the parenchyma of the testicle itself, was situated in
 an encephaloid mass, and  not in  the tunica vaginalis,  properly so
 called.
  F.  Liquid Hematocele also may be cured  by iodine injections, in
 the same manner as  hydrocele;  hematocele with  grumous clots of
 blood and concretions of degenerated fibrin, may  be cured by the
 operations generally  made  use of in cold idiopathic abscesses.
  [Scrotal Hematocele.—M. L. Gosselin furnishes a remarkable case 
ELEPHANTIASIS OF THE  GENITAL ORGANS.
417
of hematocele (Arch. Gin. de Med., 4e ser., t. V., Mai, 1844, pp. 93,
96,) of that description of hematic tumors noticed by our author, as
occurring from effusion of blood into the tissues of the scrotum, and
external to the tunica vaginalis ; only that in this case the tumor was
perfectly circumscribed, of the dimensions of a turkey's egg, and of a
pyriform shape, with the base downwards, soft and evidently fluctua-
ting, and with thin walls, not preceded or accompanied by ecchymosis.
A remarkable  sign, noticed by  M. Gosselin, and also by M. Blandin,
who operated, was  a peculiar trembling or tremulous sensation felt
in the tumor when  it was held up in the hand.   This mystery was
well explained by the narrator,  who very rationally ascribes it to the
isolated, soft clots of blood found  floating in the sanguineous liquid.
The gelly-like  character of these clots would  naturally impart the
sensation mentioned, through  the  thin cutaneous walls of the tumor.
It is well to recollect this as a diagnostic  mark, though not noticed in
hematocele of the vaginal cavity  itself, from the thickness  probably
of its serous tunic.   The testicles were sound  and  distinct, and en-
tirely separate from the tumor.  See a note of Dr. Mott, infra.  T.]

     Article  III.—Elephantiasis  of the Genital Organs.

   The scrotum, penis and vulva  are sometimes attacked with a de-
generescence, which can scarcely be cured by any other means than
by extirpation, and  which authors designate under  the name of the
Barbadoes disease,  andrum, elephantiasis, or  lardaceous  sarcoma.
M. Larrey, who states that  he has frequently seen this disease in
Egypt, calls it oscheo-chalasis.  Though  very common in India and
many countries of Africa, it remained among us for a long  time un-
known.   A proof of this is to  be found  in the  history of  the poor
Malabou,  related by Dionis, (Operat. &c, t. L,  p. 373,) on the
authority  of Father Mazaret.  Those who would  be desirous of
possessing more accurate  notions on this subject, may consult with
advantage the memoir of M. Roux, that of Delpech, (Clin,  du Alidi,
t. II.,  p. 5 to  68,) the treatise of Boyer, the  clinique of the Baron
Larrey,  and  more  especially the essay by M.  Caffort, (Turn, des
Parties Genit., &c, 1834.)  Though surgeons  were in the habit of
removing at the same time both the testicle and  its  envelopes, when
they decided upon performing an  operation for  the  cure  of the dis-
ease in question, the distinguished professor of Montpellier is not the
only one who has made the remark, that in the midst of this singular
disorganization, the  genital organs will in most cases be found to be
unaltered, nor was he the first  who made the suggestion, that they
ought to be preserved, and that we   should confine  ourselves to the
removal of the degenerated tissues.

                              § I.

  A number  of ancient authors, confounding  sarcocele and  other
diseases of the scrotum under the name  of fleshy hernia,  have ex-
pressly directed that we should respect the testicle when we find it
sound in  the midst  of the diseased   tissues.  "  Let  the skin be cut
with a razor, after  which  the  carnosity  which  you will find there,
   vol. in.                      53 
418          NEW ELEMENTS OF OPERATIVE  SURGERY.
must be separated from the testicle (coillon), which latter is to be left
undisturbed if it  is not injured."  Although upon the occasion of a
fact similar to the one now under consideration, M. Roux (Melanges,
&c, p. 233,) had already proclaimed the principle upon which Delpech
has  so earnestly  insisted, the  case  described  by this last author is,
nevertheless, one of the most remarkable which had been then known.
A man named Authier had for a long time  been afflicted with an
elephantiasis of the scrotum, which weighed, it is asserted, about 60
pounds.  The surgeon preserved as large a quantity of integuments
as he was enabled to procure about  the root of the  tumor, and from
these formed various flaps, which he used all  his efforts to shape in
such manner as to enable him  subsequently to envelope the testicles
and penis in them.  He afterwards brought  down  the  upper tegu-
mentary flap, and placed it around the penis as if to form  a  sort of
cap for it;  he then brought the lateral flaps in the same manner over
the testicles, and succeeded in  this  manner by means of numerous
points of suture, in constructing a new scrotum, and afterwards a kind
of sheath for the copulative organ.  This operation, apparently, was
attended with complete success.  But the patient, who caught a cold
also, in going from Montpellier to Perpignan, was seized at the ex-
piration of a few months with  an internal inflammation  which
proved mortal.

                              §  II.
   M. Larrey states that  he performed, in  1816, in  the  presence of
MM. Ribes and Puzin, an operation nearly similar to the preceding,
or differing from it at least only in this circumstance, that the tumor
was but from five to  six  inches in diameter.  The same surgeon, it
would appear also, had recourse to this operation when he was in
Egypt, where he  has  seen tumors of this  description which would
weigh, he thinks, 100 lbs. It would appear, moreover, that the operation
which made so much  noise at the  time, and which Imbert  de Lones
performed  on the  minister Charles de La Croix, was for the cure of a
similar disease, and that instead of sacrificing the testicle they might
have restricted themselves, like Delpech, to a  simple  ectomy of the
scrotum.   In ectomy of the scrotum, the object in view being 'to re-
move the diseased and to  preserve the sound parts, it is easy to per-
ceive that the operative process must  be modified according to an
infinite variety of circumstances, that is, according as the tumor
shall be of greater or less volume, occupy one of the compartments
of the scrotum only or both at the  same time, and  j.ccordino-  as it
shall be found  practicable to  find  in one  direction or in another
the quantity of integuments required to cover over the parts which
we are obliged to  denude, but which we do not desire to sacrifice.
Thus all that can be said  in respect to the operative manual  is  this!
that we must seek at the root of the tumor for sound integuments, in
order to cut out flaps  that shall be of sufficient size and appropriate
form, before we proceed to the ablation of the degenerated mass ; that
we should  then penetrate, while respecting those parts, down to the
sheath of the cord or  tunica vaginalis  on the one hand, and to the
fibrous envelope of the penis on the other,  should the disease  have
extended in this direction, our  object being to divest those parts of 
              ELEPHANTIASIS  OF THE GENITAL  ORGANS.          419

everything  that covers  them,  and to leave nothing behind of an
altered character; it being well  understood also, that if we  should
find a serious  lesion existing in the seminal glands, they should be ex-
tirpated at the same time.  An alteration which we mjst then  pre-
pare ourselves for, is the extreme elongation of the testicular cords;
the point to ascertain is, if this  would be a  sufficient justification for
extirpating  the testicles  if they should in other respects be  sound.
Delpech says that it is not, and  that the parts will soon re-acquire
their natural  position.  I believe with him, that M. Key might, in
fact, have been enabled to preserve the testicles in the patient under
his care in 1831, and from whom he removed an enormous scrotal tu-
mor.  May we not say the same of the Malabou  operated upon, March
27th, 1830, by M. Clot ?   " The tumor weighed  110 lbs., exclusive of a
considerable quantity of  serosity which ran out during and after the
operation."   Though where so great a mass existed as this it might
not have been any longer possible to attempt the preservation of the
testicles, this  however might have  been successfully  accomplished,
I think, in the patient from whom Raymondon removed a tumor of
the same  description, but  which weighed only 29 lbs.  The Egyp-
tian patient of M. Clot, however, was completely restored.

                              §  III.

   Should the  elephantiasis occupy the penis only, we  might  detach
the corpora cavernosa from the tumor, and then construct an enve-
lope for the organ with flaps borrowed from the  scrotum, (see Dis-
eases of the Penis.)  In most patients operated  upon, the penis buried
as it were in the midst of the mass, has had to be laid bare at the same
time with  the testicles.   It was  independent  of them, however, in
the case of the young man whom I  shall  presently speak of, and I
Was enabled to preserve  it. with the intention of afterwards treating
it by compression.   The operation, moreover,  in my opinion is posi-
tively contraindicated in  all cases where the disease is not perfectly
circumscribed and absolutely localized, and where the bistoury would
be obliged to  cut down upon  tissues that are  already indurated or
degenerescent.
   In  conclusion, the general rule  which we are allowed to lay down
in ectomy, is the following: to remove the  entire substance  of the
degenerated tissues, and  to leave intact the important organs, if
they have preserved their natural state.  As to the dressing, no other
remark is  to be made except that the  flaps of the wound are to be
re-applied with the greatest  degree  of accuracy possible, over the
parts which they are destined to cover, that  the suture, either the
twisted or  simple,  is almost  indispensable for maintaining them in
perfect coaptation, and that the lint or graduated compresses ought
to surround and make moderate compression in a uniform and regu-
lar manner over their whole  external surface, in order that no void
may be left between them and the subjacent layers.

                             § IV.
  Moreover, details of cases of tumors of this description are very
numerous  at the present  day.  M. Clot (Revue Med., 1833, t.  IV., 
420
NEW ELEMENTS  OF OPERATIVE SURGERY.
 p. 39,) states that he extirpated one successfully in 1833, which was
 sixteen inches in length and twenty-six in circumference.   A similar
 case to the one related by Dionis was noticed in 1759 by Mehee de
 La Touche.  Two observations  of Morgagni are  referable to the
 same disease.  In the patient cited by Schulte, the tumor weighed
 over fifty pounds, that of Lajoux eighty-three and a half, and Chopart
 describes one over eighty.  That mentioned  by Hale still weighed
 thirty-six and a half pounds after it had been extirpated.   M. Caffort
 extirpated one successfully two feet six inches in circumference and
 was enabled to save the testicles, (see the detail of these facts in the
 Memoir of M.  Caffort.)  The operation performed on the 21st Oct.,
 1831, by M. Gaetani, (Gaz. Med., 1835, p. 77,) for a tumor weighing
 fifty-six pounds, and in which the testicles were preserved, was fol-
 lowed with complete success.  M. Pruner  (Ibid., p. 78,) was no less
 fortunate in another case.   The patient in whom M. Gaetani removed
 one weighing 120 pounds died on the  following day.   M. Chervin,
 (Ibid., pp. 77, 78,)  who mentions one of these tumors of the weight of
 165 pounds [!?] says that the operation has been twelve or fifteen times
 performed at St. Christopher and Demerara, and  proved fatal in a
number of instances.  It would  appear that M. Weis and M. Mott
 (Gaz. Mid., 1835,) have also had recourse to extirpation.   I per-
formed it myself  (Lancette Franc, 1835,)  in one instance, in 1835,
at the  hospital  of La Charite, in an adult  aged twenty-eight  years.
There was a double hydrocele ; I saved the testicles, and the patient,
after his wounds had become cicatrized, died six weeks subsequently
of repeated attacks of erysipelas upon his thighs.

                   Article IV.—Castration.

  Castration is an operation which for a long time since has not been
had recourse to, except for the purpose of  relieving  serious diseases
of the  generative gland.   We no longer find among  us  those who
excuse Semiramis for having castrated men of weak constitution in
her domains, for  the  purpose of having no others than children  of
robust  fathers; nor others who maintain, with Brunus of Longo-
 Buco, that Seigneurs have the right to mutilate their domestics in this
 manner,  in order to confide to them with greater security the guar-
 dianship  of their women.  Even in Italy itself, there are none who
 do not now proscribe the cruel  process which had been introduced
 into that  country under the pretext of imparting a more harmonious
 and musical voice to their men.  Under this point of view castration
is no  longer in use except  among the Orientals, and in countries
 where polygamy and slavery are still permitted.

                       § I.—Indications.

  As  a therapeutical resource, castration  has been made use of for
 the radical  cure  of hernias.  It  was very much in use  formerly,
 although G. de Salicet had already condemned as ignorant persons
 those who practised it in his time, and though at the epoch at which
 de Cantemire wrote, the Albanians themselves looked upon it as un-
 necessary and dangerous.  At present it  is not recurred to but in 
CASTRATION.
421
diseases of the testicle which are considered incurable.  It is, for ex-
ample, employed when a bruise, laceration, or any traumatic lesion
whatever, has effectually disorganized the testicle, or when this gland
has become the seat of a destructive suppuration, or of a scirrhous,
cerebriform,  colloid, melanotic,  or  merely  tuberculous  degeneres-
cence.  In order that it may present some chance of success, it is im-
portant that  the disease  should  be still local and not have extended
to the viscera, and  that no trace of it can  be  found elsewhere.  A
patient who had an erectile tissue in the testicle, and who got well of
the operation, died  in  consequence of a similar tissue  in the brain,
according  to  the statement of M. Denis, (Journ. Hebdom. Univers.,
t. XIII., p. 369.)  Even where the internal organs appear to be sound,
it would be imprudent to castrate if the cord  should be found to  be
implicated to a great distance in the ring.  Nevertheless, if the dege-
neration should be of a colloid or tuberculous character, or the result
of previous chronic inflammations, and without complication of  scir-
rhus, or encephaloid or melanotic tissue, we  might attack the  cord
in the iliac fossa, as Le Dran and M. Naegele  did, and as I have  done
in three instances with success,  or we might go as far at least  as to
the depth of the inguinal canal, as was done by La Peyronie.

                    § II.—Operative Methods.

   The ancients performed castration in four different ways in those
healthy persons that were to be transformed  into  eunuchs.  Their
method by attrition consisted in making  violent bruises  upon the
organ in  order to  bring about its  atrophy;  ecrassement  was per-
formed by placing  it between two pieces  of wood ; while arrache-
ment, or tearing the organ out, (dechirure,)  or finally, excision  were
very frequently preferred.  Of these methods, which have been par-
tially retained  in the  veterinary art, the only one which remains is
the last, and which Paul, in human surgery, denominates ectomy.  In
all the processes the patient is laid upon his  back as in the operation
for strangulated hernia.
   A. Method of  M. Maunoir.—M.  Maunoir,  a surgeon  of Geneva,
proposed  at the commencement of this century, to get rid  of sarco-
cele  without  removing  the testicle,  by laying bare the root of the
cord, in order to come down upon  its vessels and to be enabled to
tie them.   According to  him, he obtained in this manner a number of
cures.  A similar operation, attended with a successful result, was
•reported  to the Academy of Medicine; but in  a patient of mine at
the Hospital of La  Charite, in 1838,  the operation was attended with
no benefit.  Moreover, if it is  presumable that it may succeed in
some cases of degenerescence, produced by a simple chronic inflam-
mation? reason would authorize  us in believing that in true  sarcocele
it would be foundinsufficient.
   B. Method of AI. Morgan.—In England,  a somewhat  different
mode is made use of.  M. Morgan (Arch. Gen. de Med., t. XVII.,
p. 613) recommends that we should  attack the vas deferens itself in-
stead of  the  vessels.  MM. Lambert and Key, (Lancet, 1828, vol.
II., p. 176,) who have adopted  the  principles of this  surgeon, each
relate a successful  case in its favor.  After having laid bare the sper- 
422
NEW ELEMENTS OF  OPERATIVE SURGERY.
 matic cord, they search for and isolate the senrnal duct, and excise
 from it  a segment of the length of one to two inches ; the wound
 should  be immediately  closed up, and  the final cure  is afterwards
 effected gradually.  Did one or the other  of these processes enable
 us to bring back the organ in some cases to its primitive condition,
 and to preserve its functions, they would most  undoubtedly deserve
 to be made trial of, notvvitnstai.Iing their uncertainty;  unfortunately
 this is not the case, and  I very much doubt that these processes will
 ever acquire  the consideration in surgery which some  persons seem
 desirous  to accord to them.
   C. Ordinary process.—Castration, properly  so  called,  comprises
 three stages which are quite distinct:  1st, incision of  the envelopes
 and isolation  of the sarcocele ;  2d, the section of the cord and the
 application of hemostatic means; and 3d, the dressing.
   I. Isolation of the  Tumor.—a. When  the integuments continue
sound, and have not contracted  any close adhesion with the tumor,
and that  the latter has but little volume, it is unnecessary, as had  al-
ready been remarked by Paul, to excise a flap from them.   In other
respects the division may be made  indifferently almost in any way,
either commencing by taking up a fold of them, or by cutting from
the skin to the deep-seated parts, as most modern practitioners do.
In  whatever manner  performed, it  is requisite* that this  incision
should be prolonged to a slight distance above the  ring, and descend
to the lower part of the scrotum.  Though there may be somewhat
less advantage  in stretching with the  left  hand the integuments on
the front part  of the tumor, while they are being divided, than in
grasping it on its posterior  side, as Dupuytren recommends, this
however is a mere matter of choice much more than of necessity.
When the skin and tissues beneath it are incised, nothing  is easier
than to isolate the testicle with  free manipulations, either by means
of the fingers, after the manner of B. Bell, or with the scissors, or
what is infinitely  preferable, with the convex bistoury,  until we  have
 passed around  its whole circumference.  For this purpose the  as-
 sistant attends to  the lips of the wound, while  the operator with one
 hand grasps the tumor, or vice versa, in order  to  stretch the parts,
 to separate them in a proper direction, and to destroy their adhesions
 by means of  the bistoury in the other hand.  The only precaution
 necessary to  be observed, is not  to carry the instrument too  near the
 penis or  the septum of the dartos muscles, from th^  danger of wound-
 big the urethra or the testicle upon tne otner side.
   b. A number of surgeons advise to proceed  always in this man •
 ner, whatever be the size of the sarcocele, piovided the skin is not
 diseased. In this there would be serious inconveniences: the meth-
 od advocated by Sharp and De  la Faye, and which Paul also adopt-
 ed, and which consists in removing a portion of skin at  the same time
 with the testicle, in all cases where the volume of the cancer exceeds
 certain limits, is unquestionably  preferable.  In such cases  an  ellip-
 tical incision, to be prolonged  like the preceding, from  above  the
 rinfr to the lower part of the scrotum, is to be  made and to include
 in tt, as is  readily perceived, a cutaneous flap of greater or less
 breadth, according as the sarcocele is of greater or less dimensions.
    c  Aumont, apprehensive of finding the pus stagnate in the bottom 
CASTRATION.
423
of the wound, wishing also to avoid the  necessity of leaving a cica-
trix in front, and  believing  also that the alterations of the skin are
more frequently met with below than above, has proposed to place
this incision on  the lower side of the tumor, and not on its anterior
surface as is generally done.   There can be  no doubt, in fact, that
we can adopt this course, as I have seen M. Roux do, and as I have
done myself;  and that this process is in some degree even necessary
when the integuments are perfectly sound in the part where they are
usually incised,  but altered  in the  opposite  direction; but would it
not  be absurd to attach any importance to the circumstance, that
after an operation of this kind the cicatrix would be placed rather
behind than in front, under the pretext that it is  more visible above
than below ?  Experience has moreover sufficiently shown that the
pus, in adopting  the ancient  method, will always readily  escape
through the inferior angle of  the wound; moreover the  process of
Aumont, from its not enabling us also to isolate the cord into the in-
guinal canal with as much facility as by  the other method, possesses
in this respect so serious an  inconvenience that I have seen M. Roux
sincerely regret having made  use of it.
   II. Section of the cord.—As soon as the sarcocele is dissected, and
the cord laid  bare to beyond the  limits of  the disease, the surgeon
should attend to the separation of the  parts  which he designs to
remove.  This is the point upon which there has been  the greatest
variety of opinion among practitioners.
   Two methods, even very distinct from each other, have, resulted from
this  want of harmony.   In one the  cord or its vessels are tied before
proceeding to its section;  in the other a course diametrically opposite
is adopted, and each method comprises a great number of different
processes.
  a. Ligature of the cord in mass.—Paul of Egina, after the manner
of Celsus, constricted the whole cord between the ring and  the dis-
eased mass, in a strong ligature.  The majority of operators at every
epoch have proceeded  in the same way; but  there are those who,
after the  manner of Purmann, assert that the  ligature ought to be
placed as near  as possible  to the ring, while  others, like Barbette
and  Bertrandi, apply it immediately above  the epididymis.   Some
again, like Haenel, place it on an intermediate point.  Though there
may be those who, after the manner of Franco and Pearson, tighten
the  ligature immediately with as much force as  possible; there are
many on the contrary who, like O. Acrel, make such a degree of
constriction upon it only as will be sufficient to interrupt the flow of
blood.   There are others again, as  Gauthier for example, who even
only make constriction  upon the ligature gradually,  renewing this
every day until it has completely cut through the tissues.  Pare and
I leister (These de Halter, French  trans., t.  II.) recommend  a liga-
ture several times doubled to be passed through the cord, so as to tie
the two  halves  of the latter separately.   Ravaton, with a view of
leaving the vas deferens entirely free, places his ligature in the man-
ner of Pare, but he constricts only that half of the cord which seems
to him to include the vessels.  Some surgeons finally, with Birch, as
quoted by Sprengel. apply a precautionary ligature very high up and
another an inch lower down, by means of which latter they strangu- 
424          NEW ELEMENTS OF  OPERATIVE SURGERY.
late the vessels before excising the parts below.  It is to be remarked
moreover that Theden and Flajani have deemed it advantageous to
interpose a small compress between this  ligature and the  spermatic
cord, while Pelletan prefers merely a piece of sheet-lead.
  b.  A separate ligature on  the vessels.—Those who amputate  the
testicle at first differ, nevertheless, on the subject of the  treatment
afterwards required  by the cord.  Cheselden having remarked that
a ligature applied upon the cord had, by gliding in front, made pres-
sure upon the principal  vessel, and had thus suspended the flow of
blood,  was one of the first to propose that its arteries should be liga-
ted separately.  Le Dran recommends that we should surround the
cord with a  precautionary ligature, and afterwards make pressure
upon the vessels with the fingers at some distance below, and that
we should not tighten the thread except in cases where the pressure
had proved insufficient to arrest the hemorrhage.   White  and Korb
state that they have succeeded  by imitating the process of Le Dran.
J. L. Petit applied a small graduated compress upon the ring, with-
out employing  any ligatures;  while  Pouteau  confined  himself to
keeping the end of the  cord  turned back upon the  pubis.  Runge,
after having carefully dissected  it, twisted it several times upon itself
before  separating the testicle from it, and also dispensed with  the'
ligature.   Finally Smett and Schilling maintain that such precautions
are useless, inasmuch as men who castrate themselves in a  fit of
anger or despair, make use of no means to arrest the flow of blood,
and yet nevertheless do  not die of hemorrhage.
  c.  Appreciation.—It would be erroneous to suppose that these va-
rious opinions are no longer in  existence  at the present day.   The
ligature in mass has numerous partisans, though on the  other hand
there are many surgeons also who only isolate and ligate the vessels
separately before  dividing the cord.   1st. Bichat (Roux, Melanges,
&c, p. 230) for example, and M. Roux and M. Chas. Bell, have  re-
commended that we should divide the cord down to the vas deferens,
and then to grasp and ligate its  arteries before making the section of
the duct.  Finally, others detach the sarcocele, as soon as it is sepa-
rated from its envelopes, and  immediately afterwards search in  the
upper  end of the cord  for such vessels  as might bleed, either by
means  of a hook, or tenaculum, or with the forceps.   As in the greater
number of patients, the artery or arteries of  the cord are of such in-
considerable size, as to lead to no apprehension in leaving them to
themselves after having divided them, it  is readily  conceived that
friction after the manner of Le Dran, compression  as  made  use  of
by J. L. Petit, and torsion or reversion by Runge, has  been found
to answer, and might be made trial of almost without any danger,
by any person who should desire to do  so.  Nor can it  be dispu-
ted also that  the ligature, after  the manner of Bichat or of Desault
Boyer, Dupuytren, Delpech, and  MM.  Roux, Mott,  and  Serre!
(Compte Rend, de la Clin, de  Montpellier,  1837.) who adopt  the
principles of Cheselden or of Bromfield, might succeed equally well.
2nd. Nor should we throw any obstacle to the accomplishment of the
cure, by embracing the cord in its totality or  only in part, and in ma-
king upon it direct or graduated  constriction.  The important point
in this  matter therefore,  very naturally would be, to know which in 
CASTRATION.
425
reality is the most advantageous or most prudent, which is the easiest
and most certain, whether to ligate in mass, or not to apply the liga-
ture until after having detached the  organ.   The opponents of the
first method, Siebold  among others, adduce as an argument for its
rejection, the danger of comprising in the  same ligature the vas de-
ferens, the  nervous branches of the  renal  plexus which  accompany
it, the branch furnished by the genito-crural nerve, together with all
those other tissues which are not required to be included;  also they
contend  that a ligature of this kind must produce violent  pain,  and
incur the risk of .causing  convulsions or  even tetanus,  and finally,
that the ligature is sometimes very slow in cutting through the parts,
and protracts to a considerable degree the period at which  it may be
removed from the wound.  Some have added that the constriction of
so great a number of different organs would soon cause  the ligature
to be relaxed, when it would no longer be found  sufficient to close
the arteries.   To all this it may  be rejoined, that immediate strangu-
lation, causes  a somewhat acute degree of pain only for a few  mo-
ments, even though the continuity of the  nervous branches and the
vas deferens have been divided by it; that  hemorrhage has  never
been seen to take place from vessels strangulated in this manner ;  that
tetanus and nervous symptoms are no more to be apprehended from
this method than from any other; that  the patient thus treated by
Morand, and who died tetanic, owed his disease to  quite another
cause; and that  M.  Couronne,  (Revue Aled., 1827, t.  III., p. 420,)
moreover, has published the case of a man, who also died of tetanus,
in consequence of castration, even  though  the  cord had not been
tied in mass.  3rd. I have seen this operation performed at the hos-
pital of Tours by M. Gouraud at least twenty times in the space of
four years,  also by MM. Richerand and Cloquet at the hospital of St.
Louis, by M. Bougon at the hospital of the School of Medicine, and
by many other practitioners besides ; I have peformed it myself more
than thirty  times, and in all  these cases, which amount to more than
100, the ligature  in mass was used without  there ever having re-
sulted any inconveniences which could be reasonably imputed to it.
Employed also by M. Sachs, (Rust's Handbuch der  Chir., vol. IV.,)
who operated in this manner on both  sides, by M. Robert  de  Chau-
mont, (communicated  by the author,)  and by  M. Naegele, Somme,
(Bull, de la Fac de Paris,  t. VI., p. 25,) M. Gama, (Sornay, Thise,
No. 86, Paris, 1837,) M. Golfier, (Presse Med., t. I., p. 452,) and M.
Pasquier. the ligature in mass, which M.  Boussion,  (Bull. Med. du
Midi—Journ. des Conn.  Med., t. IV., p. 365,)  has  also  seen  per-
formed five or six times at Bordeaux, and which  is no less approved
of by M. Cazenave, is therefore  at the present day the  only method
which actually deserves to  be received  into general use.  The ex-
perience  and  arguments of Mursinna, Wilmer,  Loder,  and  Dietz,
who are quoted by Sprengel, have moreover fully refuted  the objec-
tions of Siebold on this point.  It is true that with the separate lig-
ature, if the proper precautions are taken, success is no less certain ;
but it is evident that it presents more difficulties, that  we have in
some cases trouble in finding the vessels, that the explorations to
which we are then obliged  to have  recourse, uselessly  prolong the
operation, and that quite a copious hemorrhage, has in more than one
  vol. in.                      54 
426
NEW ELEMENTS OF OPERATIVE SURGERY.
instance come on from the end of the cord  after the dressing  has
been applied.  4th. Another accident which also might create alarm,
as I had occasion to notice in a patient operated upon  by M. Roux, is
peculiar to this operation.   While this professor was looking for  the
artery, the seminal cord itself escaped from his fingers, and slipped
underneath the integuments which had been preserved;  he hastened
to sieze it with the dressing forceps, and to bring  it outside in  order
to pass a ligature around it, which was applied somewhat negligently;
the bleeding appeared to have been arrested, but towards the evening
copious hemorrhage came on, which returned several times during the
night and threatened to become fatal.
  d. Authors have spoken a good deal of this tendency of the cord to
retract itself; hence comes their pro visionary ligature and  a multi-
tude of other  precautions.  Nevertheless none  of the  constituent
portions of the cord are contractile.   The spermatic vessels and vas
deferens, after having been a long time drawn upon  and elongated,
appear  to be the only portions which are  capable of retracting to-
wards  the belly after they have  been relieved  of the weight that
dragged upon them.  As  to the tunics which unite them together or
envelope them, we cannot perceive how these can effect the slightest
retraction in that direction.   The fibres  of the  cremaster, at  the
utmost,  might be capable of drawing the  parts back  to the distance
of a few lines.  It is  incorrect, therefore,  to say that  the  cord, after
having been once divided,  must necessarily recede to  a considerable
distance upwards.   It  has  not been  at the present time only, how-
ever, that  any tendency of this kind had been denied to it.  M. Flau-
bert a long time since had noticed the error which  I have just pointed
out, and M. Senateur has  collected arguments and facts well calcu-
lated to refute it, at  the same time  that M.  Chas. Bell, on his part,
opposed this idea in England.  The following, in fact, is what takes
place:  If  the sarcooele is  ancient  or voluminous, or  if in any way
whatever  the cord has undergone a  considerable degree of elonga-
tion, it has, in fact, as soon  as it is divided, a tendency to regain  the
interior  of the inguinal canal, but its  constituent portions then yield
only to their appropriate elasticity, and have no other  result in view
than that of becoming approximated  somewhat nearer to their prim-
itive position.  In all cases  where this elongation has not taken  place,
and where the  degenerated testicle  has remained at  the same dis-
tance from the  ring, no result of this kind  is seen and no  apprehen-
sion can exist of the  retraction  in question.   It  may require some
attention, in fact, only in a small number of persons, as, for example,
where the disease does not admit of our  separating  the  cancerous
mass at  an inch at least from the inguinal  opening; from whence it
follows,  that it  is hardly necessary to take it into consideration so
long as the tumor has not implicated  the cord itself.
  e. Arnaud, Marechal, Garengeot, Bertrandi and other practitioners,
considering that the root  of the cord is found to be enveloped in
fibrous tissues and lamellae  that are not distensible, proposed to divide
the ring in order to prevent  the strangulation of the  cord, a  stran-
gulation to which they attach a number of dangers, but which must
necessarily be very rare, since no  practitioner in  our times  makes 
CASTRATION.
427
any mention of it, although  the advice of Garengeot has been gen-
erally neglected.
  /. As to the manner of dividing the cord, it has necessarily varied
but very little.   The red-hot iron, which was  preferred by Roger
of Parma, Brunus, &c, no longer finds any partisans.  The  scissors
used by Scultetus are manifestly less suitable than the bistoury.  In
making use of this last instrument it is  quite unnecessary to incise
the organ  by a  bevelled section, as recommended by  Le Blanc.
While  an assistant supports the testicle, the surgeon grasps the sper-
matic cord with his left  hand a little below the ring, or at the point
which  sustains the ligature, and divides  it with a single cut from
behind forwards,  or from before backwards, and perpendicularly to
its axis.  It is not probable that hereafter  any person will recommend
that the ligature should be allowed to perform the duty of cutting its
way, by degrees, through the  parts, as in treating a polypus, and as
is recommended by Runge or  Le Blanc.
  III.  If the flaps of the wound should be too large, it would be ad-
visable to exsect them immediately.  Otherwise we should incur the
risk of their rolling up inwards, and  ultimately rendering the cure
tedious and difficult.  This disposition in the sides of the scrotum to
roll up on their inner surface appears  to  be naturally explained by
the anatomical arrangement itself of its  tissues: the remains of the
cremaster, should  this muscle  have not been completely destroyed,
together with  the layer formed  by the dartos, from their both being
endowed with a certain degree of contractility, retract more or less
upon themselves  and necessarily draw upon the cutaneous tissue in
the same direction.
  D. Process of Zeller or Kern, (Rust's  Handb. der Chir., vol. IV.)
—A person of the name of Acoluth, having a  special dread of any
kind of hemorrhage, proposed  to draw the tumor downwards, and to
strangulate it with  a silken  ligature placed above its root, in order
that its separation  might take place gradually.  Haly Abbas, and
before  him also Aristotle, who had also given the advice, recommend
that we should immediately excise the testicle with a razor below the
ligature.  In Germany a different process is adopted.  Zeller, upon
the strength of the fact that certain maniacs and others have' them-
selves  amputated their testicles, together with  the scrotum, with  a
single  cul, suggested that  this method might  be systematized and
transformed into  a regular  process.   With this view he grasps the
sarcocele with his left hand, causes the skin to be drawn back a little
at the  upper part, by the hand  of an assistant,  and removes with  a
single  cut of the  bistoury or knife the entire tumor divested of its
envelopes, and  afterwards, in  order  to prevent  the hemorrhage,
merely keeps at  the bottom of the wound a sponge saturated with
cold water.  A surgeon  of Vienna, who has since been desirous of
bringing this method into repute, hasv employed it in a great number
of instances, and according to him, with unvarying success, by en-
grafting upon it, however, an important modification, since he adopts
the precaution of not abandoning the cord until he has surrounded  it
with a strong ligature.   The method of Zeller  enables us to remove
the testicle with surprising rapidity, and  makes  castration an opera-
tion as simple as  it is easy.  It appeared to me  moreover, in the two 
428
NEW ELEMENTS OF OPERATIVE SURGERY.
 patients who were operated  upon in this manner by me, that the in-
 teguments, from  not having been  dissected, allowed  of the wound
 being closed up  with  much more  rapidity than  by the ordinary
 method.  But it  renders the ligature in mass upon  the cord  more
 difficult, and evidently  can be no longer applicable when the tumor
 is somewhat voluminous, or when its envelopes are altered.
   E. Process of  the author.—If the envelopes of the tumor are suf-
 ficiently pliant and sound to be drawn  backwards, I take up a fold in
 them which is kept tense and flattened  by one assistant, while  an-
 other disengages,  raises up, and draws the sarcocele to the front;  I
 then pass a ligature at distances of four to four lines through the dou-
 ble tegumentary tissue, and as near as  possible to the tumor, taking
 care to  pass one of the four  portions under the  cord  above the dis-
 eased parts, and  to strangulate this last  upon a graduated  com-
 press.   Then removing the entire mass by means of the bistoury, as
 in the process of Kern, I have nothing more  to do than to knot the
 threads, in order  to  complete  the  suture and the operation.   Two
 patients whom I treated in this manner, recovered perfectly.
  F. The ordinary process, moreover, may be very easily combined
with the temporary ligature upon  the  cord, either directly or indi-
rectly.  Being passed through the skin or around the cord, after it  has
been laid bare, all that  is necessary  is to fasten  it by a knot, and af-
terwards a bow  knot, on some supple substance; we may in this
 manner loosen or  tighten it according as it may be required, and can
 withdraw it from  the third to the sixth day.
  G. Ilio-Inguinal Sarcocele.—The testicle which we  are about to
 remove, in place of occupying the scrotum, or hanging outside, may
 be confined  and  arrested  in the tissues of the walls of the belly, at
 the interior portion of  the inguinal canal ; and  this may take place
 from the individual never having had  the testicle in the scrotum, 01
 from its having accidentally  ascended to that point, as occurred in  a
 remarkable case mentioned by Rossi, or it may be because the cord
 is implicated in the disease of the testicle.  However  this may hap-
 pen, it may be transformed there into  the condition of sarcocele, in-
 stances of which  are related by Chopart, Boyer, and M.  Rheinlen-
 der, orr the authority of Robert, (Journ. des Prog., t. XIII., p. 125.)
 It may  readily be conceived how delicate and dangerous the opera-
 tion must be under  such  circumstances.   In the first  place, before
 commencing with it, how can we determine precisely the limits of
 the disease ?  Then again it is to be apprehended that in performing
 it we may open into  the peritoneal cavity, contrary to  our intentions,
 as  happened to M. Naegele, (Arch. Gin. de Med., t. XIII., p. 423;
 Journ.  des Prog., t. XIII., p. 156,)  or  that  we may even be obliged
 to do this designedly, in order to remove the entire disease.   In such
 cases, therefore, we must incise layer by layer the whole thickness
 of the tissues which envelope the tumor, and isolate it little by little
 by a careful dissection, keeping constantly present to  our minds the
 proximity of the peritoneum, the epigastric artery, and even the iliac
 vessels. Upon the supposition that we might apparently lay bare the
 cord with ease, it would be more prudent, under such  circumstances
 particularly, to apply  to it  the  ligature in mass, than to attempt to
 strangulate its vessels separately.  Should a chronic phlegmasia have 
CASTRATION.
429
blended its different lamella? with  the surrounding layers, this mode
of applying the ligature would be still more suitable, and  the thread
ought to be introduced by means of a curved needle.  In the case
of Rossi, related by M. Piussan, (These, No. 215, Paris, 1825,) it be-
came necessary to divide the cord at more than three inches  above
the ring, yet the patient  recovered  notwithstanding.  I have per-
formed this operation three times.  In the three I laid open the whole
anterior wall ofrthe inguinal canal, and was obliged  to isolate the
cord as far up as into the iliac fossa, at which part I applied to it the
ligature in mass.   I did not find the operation attended with any se-
rious difficulty.  The tumors were encephaloid.  One of the patients
has continued well since 1836; in a second, a tumor of the same de-
scription developed itself in the groin at the expiration of a year; of
the third, I have received no intelligence  since  he was discharged
from the hospital.  Should the inguinal canal only be implicated with
the scrotum, the operation is then still practicable.
   H. Whether the ablation of the sarcocele has been effected by this
or that method, the wound always contains a certain  number  of ves-
sels wh;ch should engage the attention of the surgeon before he pro-
ceeds to the dressing.  Even if we set aside those of the cord, we
find one or two external to this, and  these are the vessels which are
usually the largest in size ; some also will be found at the lower an-
gle of the division, and which  come from the pudic artery by the
superficial  artery  of the  perineum :  finally, it  frequently  happens
that we  meet  with one on the inner side, and  which is one  of the
branches of the artery of the septum of the dartos muscles.
   I. In most cases these vessels cease to bleed at the moment when
the operation is terminated, and in  some  persons  it  will prove un-
availing to attempt to find them afterwards ; on which account it has
been recommended to make use of  the ligature or torsion to these
vessels in proportion as they are opened.   It  rarely happens, how-
ever, that a hemorrhage takes place  from neglecting to tie them, pro-
vided they have not shown themselves when the sponge is applied to
detect them on the surface of the wound.  Schmucker (Rougement,
Bibliot. du Nord, p. 38), omitted in one instance to  apply the ligature
to the cord, but no  hemorrhage  followed.  M. Puchot (These, No.
207, Paris, 1835), noticed the same thing in a maniac.  A patient, in
whom the testicle  was hanging down  from a wound,  had it removed
on the fourth day ; the vessels were not tied ; the wound was united
by means  of the  whip  suture, and  the patient recovered (Roulot,
Journ. des Conn. Med-Chir., t. III., p. 76.)
   II. Whether, however, the ligature has been applied to the  vessels
or that we have not considered it necessary to pay any farther  at-
tention to them, it  must  be recollected  that in a considerable num-
ber of cases  the  dressing becomes wet with blood at the expiration
of three or four hours, or in the course of  the night following the
castration, without,  however, any actual  hemorrhage having taken
place.
   I. Dressing.—I. The ancients had recourse to the  suture after the
removal of the testicle, and frequently endeavored  to effect union by
the  first intention.  From the termination of the seventeenth century,
however, no other treatment scarcely has been  used  but that  by 
•
 430          NEW ELEMENTS OF OPERATIVE  SURGERY.

 second intention.  A considerable number of English, German and
 American surgeons, and with them Delpech and other practitioners
 in the south of France, have, it is true, again endeavored to bring into
 repute the first named method, but I have not found either in the work
 of  M. Serre nor in foreign publications, any well established fact in
 proof of the perfect cicatrization of  a wound of this description by
 first intention.   Of the three patients operated upojn by  M. Serre,
 an  account of which has been published by M. Alquie, (Gaz.  Med.,
 1837, p. 476,) one was cured in 15 days, the second in 31  days, and
 the third in two months and a half!   In the first place, it would be
 necessary that there  should have been no ligature  employed, that
 we should have  restricted ourselves to the  torsion only of all  the
 arteries, and  that we  should  finally have been  enabled to  place  the
 lips of the wound and the integuments  which  had  been preserved,
 in perfect contact with the subjacent tissues.   The suture, either sim-
 ple  or twisted, would in such cases become absolutely indispensable;
hence would arise a greater degree of pain and numerous difficulties
to be overcome unless we followed the process I have pointed out.
  II.  The usual practice is  attended with infinitely less embarrass-
ment.  A piece  of  fine  perforated linen,  besmeared with  cerate, is
spread out like a veil over the  entire traumatic surface.   Over this
are  immediately applied some small  balls  of lint.  The sides of the
 scrotum  are  also padded with lint in order to prevent their fric-
tion against the  upper part of the thighs, while several plumasseaux
 cover over the whole.  Long compresses  and then a large suspen-
 sory or a double spica complete the articles of  dressing.   The acci-
 dents to  be apprehended are the same as those which occasionally
 succeed the other great operations in surgery, and require  the same
 treatment.
  a. Hemorrhage, when it takes place, is far from always requiring
 the wound to be hastily laid open in order to discover its source and
 to tie  the vessels.  We shall frequently find  ourselves enabled to
 arrest  the  bleeding by sprinkling and saturating the dressing with
 cold water or lead water, and by renewing these applications at least
 once every hour.  If however the bleeding should continue to such
 extent as  to enfeeble the patient, or give rise to the apprehension of
 an internal effusion, it would  become necessary immediately to take
 off  the dressing,  remove  the clots of blood, and tie the  artery or
 arteries that were  not closed  up, or in  fact to have recourse to
 tamponing, styptics, and even to cauterization, should the danger be
 imminent.
  b. Should  the  ligature  in mass have been  preferred,  it is to be
 apprehended, if  the  constriction  has not  been carried so  far as to
 strangulate the tissues completely, that the extremity of the  cord will
 retain its vitality and become transformed into a reddish colored
 granulation or sort  of cauliflower, which,  as has been  remarked by
 J. L. Petit, and as I myself have seen in a patient operated upon at
 the hospital of St. Louis by M. Cloquet, may be confounded with the
 neighboring borders of the wound, in such manner as to give rise to
 subsequent difficulties.  It is however  probable that even in such
 cases  the ligature would  finally cut  through the cord it embraced, 
CASTRATION.
431
and  that the vegetation in question might  be repressed by means
of astringents or caustics.
  c.  If in spite of all  these precautions  the borders  of the  wound
should have  become inverted, we might, provided the suppuration
should not be too abundant, endeavor to approximate the sides of the
wound to its  bottom  and keep them compressed in such manner as to
effect their adhesion  by secondary immediate reunion.
  III.  If all  these precautions are made use of the patient will re-
cover  in  three weeks or a month, sometimes in  twelve or  fifteen
days, rarely sooner,  but sometimes at a later period.  Castration in
itself is not a serious operation; it causes but very little reaction and
is rarely  fatal.  If however we  should insist too  strenuously upon
immediate reunion it may give rise to a purulent inflammation or a
sort  of phlegmonous erysipelas, which, ascending along the cord, in-
volves the inguinal canal, and may reach the fascia propria or the
peritoneal cellular tissue of the fossa iliaca.   In some cases also the
phlegmasia, though continuing to be sub-cutaneous, will follow the
course of the fascia superficialis and spread with this over the whole
iliac region, in such manner as to  place the life of the patient in immi-
nent danger.  Surgical anatomy, a subject which  I have elsewhere
treated of, (Anat. Chir., t. II.,  edit.  1837,) perfectly explains  this
phenomenon.
  [New Practice of Incision into the Tunica Albuginea Testis.—In
cases of parenchymatous orchitis, i. e.  where, as is occasionally but
not frequently seen, the testicle in young men between the  age of
nineteen and twenty-four, from certain pathological causes, becomes
severely inflamed  and strangulated  as it were, within  its  investing
tunica albuginea, (peri-testis,)  and which might and  does result in
suppuration  and loss of the testicle, M. Vidal de Cassis, of Paris,
has recently recommended a bold practice,  (Journal de Medecine et
de Chirurgie Pratiques, Paris,  October,  1844,)  which has made
some sensation in that capital by  the success which has followed it.
It consists in making incision, layer by layer, to the  extent of nine
lines down  to  the albuginea, which was  readily divided, and by
which  the testicle was laid bare.  There is no serosity within the
tunica vaginalis ; union without any suppuration takes place between
the testicle and the vaginalis at the incision.  In one case, in which
it proceeded from a debauch after the cure of a blennorrhagia, the
latter returned  as  soon as the division of the  albuginea was made.
In M. Vidal's two cases given there was a cure effected without any
previous depletion, and in  support of this treatment we have a case
of M. Cullerier, (lb.,) where the symptoms  of pain in the  part  and
cord were aggravated by bleeding, poultices, purging and extensive
leeching to the  cord, (viz: twenty-five leeches,) and in which nothing
but division of the  albuginea checked the  disease.   M. Vidal has
already treated, by  his mode, fifteen cases with success, (vide also
Cormack's Monthly  Journal, fyc, Jan., 1845, pp. 70, 71,)
  New Treatment of a species of Fungus of the Testicle.—Mr. Syme
of Edinburgh (Cormack's Loud, and Edin. Monthly Journ. of Med.
Science, January, 1845, p. 1, &c.,) proposes in cases of those  well
known fungoid growths of the testicle described by Lawrence,  (Edin-
burgh  Medical and  Surgical  Journal, year  1808,)  and which pro- 
432
NEW ELEMENTS  OF OPERATIVE SURGERY.
 cure some ease to the patient by ultimately making their way by ul-
 ceration  through  the scrotum, to discard escharotics or the knife,
 as hitherto used, but in lieu thereof, to make an elliptical incision free-
 ly through the teguments  of the scrotum, and after excising the hard
 and corrugated portion around the fungus, and dissecting these tegu-
 ments back, and detaching them from their connections, and abrad-
 ing the edges of the wound, to reduce by a sort of taxis the hernia-like
 protruded excrescence within the scrotum, and then  to unite the lips
 of the incision over the  included  tumor, by stitches.  The  pressure
 he has found, by this treatment, will in a  short time effectually cure
 the disease, by  causing an absorption of the exuberant granulations,
 which the microscope proves this  tumor to consist of.   The brown
 divergent strias are found  to be the tubuli seminiferi, and the white
 substance which separates these tubuli to some distance apart, is  as-
 certained to be  organizable lymph, which being absorbed, leaves  the
 former (the tubuli) and the testicle to which they belong, in  a natu-
 ral state.  The surface of the fungus itself  being also ascertained, as
 he says, by Mr. Goodsir, through the microscope, to be of a  granula-
 ting nature, readily unites with the corresponding internal raw sur-
 faces of the integuments.  The parts under this treatment speedily re-
gain their normal size and condition—a result which certainly would
not have been  anticipated, if we were to be guided  by the received
notions on all fungoid growths.   The discovery of this practice by
Mr. Syme, should it be confirmed by future trials, shows the valuable
acquisitions probably which are yet in  store for therapeutics by the
light to be thrown  upon morbid structure by the microscope, as well
as by organic chemistry.
  Scrotal Tumor.—Diagnosis of a Tumor in the scrotum of a living
adult, containing debris of a Foetus.—The honor of establishing one
of the most delicate points of diagnosis, that has ever  occurred, fortu-
nately fell to the lot  of one of the most learned, practical, and dis-
 criminative of living surgeons, our author,  M. Velpeau, viz., in 1840,
 at the celebrated hospital of La Charite, to which he  is attached, and
 in the year immediately succeeding that (1839) in which this work
 was published.  It is unnecessary to remark how much sensation this
 case created throughout the learned world, and  it would be quite
 superfluous for us to add our own  individual  homage to the honors
 that have justly accrued to our distinguished author  for this brilliant
 result of that masterly skill, ready tact,  and close  familiarity which
 he possesses of the most complicate anatomical relations of parts, both
 in their pathological and physiological conditions.   Of the truth of this
 remark, this diagnosis unprecedented by any analogous circumstances
 in the history of surgery, furnishes  a most conclusive evidence.  The
 patient, whose name was Gallochot, aged 21,  (see an interesting  ac-
 count  of the  case, as drawn up  by Dr. N. Victor  Izokalski, in  the
 Gazette  des Aledecins Praticiens, de  Paris,  and copied   into   the
 Archives  Generates  de Medecine de Paris,  3e  et  nouvelle serie,
 tome VII., 1840, p. 299  to  p. 313; see  also the notes appended to
 the case by the Editors  of the Archives, Ibid., loc. cit., p.  302 to p.
 313,) was received into  La Charite, Jan. 18, 1840, with  a tumor of
 the size of a turkey's egg, on the  right side of the scrotum.   It was
 perfectly insensible, and  had,  he related on the authority of  his 
CASTRATION.
433
mother, been in that state, and of the same size from his earliest in-
fancy, which assertion there was reason to believe was true, as it was
confirmed by the family physician.
   The fact of the insensibility  of the tumor, which the patient said
gave him no  pain, even when he thrust a knife through it, was also
confirmed by the numerous cicatrices upon it.   The position of the
tumor was external to the scrotum itself, its shape of a rounded form,
and the skin which covered it was white and strongly contra-distin-
guished from the deep brown color of the skin of the scrotum gene-
rally, both  by this circumstance and by the peculiar fine hairs  upon
it.   While the skin of the tumor also was insensible to  the touch or
puncture, that of the scrotum was exceedingly sensitive.  Generally
this morbid  production had the feel of a fibrous mass of  different de-
grees of hardness.  In the midst of its tissue there was perceptible,
when it  was  examined posteriorly, an  indurated substance which
conveyed the idea of something osseous.   At this part were noticed
three fistulous openings, through which exuded constantly an unctu-
ous matter,  (matiere grasse,) which  resembled neither pus nor sero-
sity.  Through one of these  fistulous apertures protruded a tuft of
very fine hairs, which had existed there before  hair had  appeared on
the pubis. The testicle and epididymis were situated on the inner side
and appeared sound, except that they were slightly hypertrophied.
The spermatic  cord also seemed healthy, and the functions of the
parts were unimpaired.  The  patient said he never had  the venereal
disease, and the tumor caused  him no uneasiness or trouble.  M. Vel-
peau, proceeding in his examination upon the ejective method,  (voie
d'exclusion,) at length diagnosticated a monstrosity by inclusion, or a
tumor composed of the detritus of a foetus.   On the 29th of January,
1840, he proceeded to the operation, circumscribing the tumor by a
circular incision on the skin of the scrotum, after which,  the diseased
mass was, after a careful and minute dissection, completely separated
from the neighboring  parts.   The testicle, and even the  tunica va-
ginalis, were both respected, and were in sound condition, as had
been beforehand diagnosed.  A  good deal of blood flowed, requiring
three ligatures,  after which the wound  was neatly closed by four
pins secured by the  twisted  suture.  Violent inflammation of the
scrotum and febrile reaction ensued, which, notwithstanding active
depletory means, ended in death in twenty-four hours after the oper-
ation, by means of metastatic abscesses which developed themselves
in the chest.
   Dissection of the tumor.—A  transverse incision exhibited several
cysts of various capacities and  containing different matters.   The
largest contained a fatty matter of a greyish color, composed of small
isolated particles, but united to each other by a  gelatinous substance.
Another cyst, of a chesnut color, was also filled with fatty matter, of
deeper color,  and in this was found a quantity of very  fine hairs.
Others contained  a  semi-liquid  substance, perfectly resembling the
vitreous humor in consistence, but of a yellow color.  The compact
portion of the tumor had none of the normal or abnormal characters
of known tumors ; it was of a fibrous consistence, but quite soft, and
of a rosy tint in its interior.  It contained also distinctly  recognizable
masses  of fat.  The most remarkable  contents of the tumor, and
  vol. in.                        55 
434
NEW ELEMENTS OF OPERATIVE  SURGERY.
which were situated near its middle portion, were a number of bones
arranged in different ways and articulated with each other, (plusieurs
os diversement disposes, articules les uns avec les autres.)   M. De-
meaux, (an interne of M. Velpeau,) by means of a careful and minute
dissection of these, was enabled to isolate them into three groups.
The largest one appeared at •first to consist of three principal portions,
one of them, the  most considerable,  consisted of an osseous column
of great strength and somewhat irregular; from one of its sides pro-
jected a prolongation which was curved upon itself in two different
directions;  on the opposite side were two osseous fragments articu-
lated together ; and the whole united to the osseous column just men-
tioned.   The inference was  almost irresistible that these bones were
those of the pelvis.  The second group was composed of long bones
articulated to each other by means of a fibrous mass.  Among this
group was  a flat bone.  The  third group was composed of several
flat bones, and of a series  of small osseous nuclei, (petits  noyaux os-
seux,) united together.   These last were probably the remains of the
head and spine.   These specimens were transmitted by M. Demeaux
to the Anatomical Society, where the diagnosis of M.  Velpeau was
recognized to have been fully made out.
   This case, as well as the  diagnosis, are, as we have said, without
any known parallel in the annals of surgery.   Extra-uterine masses
or debris have, however,  been found at various periods of life,  both
in the interior and on the external parts of the body, and have been
described by various authors.   For  a  very learned and  interesting
account of the history of extra-uterine tumors we refer  the reader to
the observations we have already alluded to, and which are appended
to the above extraordinary case by the editors of the Archives Gene-
rates, (loc. cit. supra.)  M. Geoffroy St. Hilaire, the celebrated natu-
ralist, (now deceased) denominates the individual in whom such tumors
are found an autosite, while the tumor or fcetal  germ itself is denomin-
ated parasite.  This distinction would seem to apply to their actual
condition when discovered, during some period of  extra-uterine life,
either at birth or afterwards.
   What  the condition of such  union  is  during  intra-uterine  life,
however, or at the  commencement of it in the ovarium  is  another
question.  The Archives' editors consider that there must have been
at first, either two distinct  and  isolated (and, at the time,  perfect,  as
we suppose) germs, that one has penetrated  into the other, or  that
both germs were originally united in the same ovule, i. e. as we in-
terpret the editors, were contained in distinct ova and  both ova in-
cluded in one of Graefe's ovules, for example.  In either  case, how-
ever, it is clear that one has been arrested in its development, and
that  the organization of the other has predominated over the last at
some period of intra-uterine existence.  But  if we suppose  distinct
or separate or isolated  existences from  the  beginning, ab  ovo we
must, to carry out  the principle, suppose  two  embryos either in' the
state of twins united m separate ova, or together in one  ovum  and
yet each, in this latter, having an independent  existence, so to speak
In the Siamese twins the presumption is, that  if distinct ova existed
as must have been the fact, these ova were indissolubly united from
the very first moment that the  spark of organic life was infused into 
CASTRATION.
435
them.  It would seem, in such cases,  that the two organizations,
however, though united by a vinculum,  must be external to and iso-
lated from  each other.   Therefore, in  the  remarkable case under
consideration, it is impossible for us to resist the conclusion that the
ovum of the perfect individual must have originally contained within
itself by  a species of involution, the ovum of the being whose devel-
opment was  arrested and, as it were, crushed  in embryo.  If the
latter was a parasite it was of the entozootic kind.  When both com-
menced their existence with the punctum saliens, both may have been
of equal development or power, though of unequal dimensions,  as
one was within  the other.  At all  events, it is to us clear that the
one which now exhibited itself only under the aspect of an obscure
vegetative  life,  in  imperfect  portions  of a foetus,  was  contained
throughout  the  whole  of its organization,  completely within the
other: in other words, was at first an ovum  within an ovum, i. e.  an
ovum in ovo, or  an imperium  in imperio.  Without, however,  pur-
suing this inquiry farther, and which  falls more directly within the
province of embryology, obstetrics, and pathological surgery than it
does within the divisions embraced in this work, it may be observed
that the perfect authenticity of the facts in the case of M. Velpeau,
and  the  interpretation we have ventured to give in relation to the
primitive condition of the individual and of his tumor  during intra-
uterine existence, are calculated  to impart  some degree  of proba-
bility to  a  narration referred to in the Archives, (loc. cit.) hitherto
deemed  fabulous,  and  which asserts, on the  authority  of Gabriel
Clauderius, (see Pauli Observationes rarce, selects et curiosa, Lipsise,
1760, p.  85,) that in the year  1762  the wife of a miller  gave birth to
a  strong and healthy female child with a belly of extraordinary
dimensions, which infant some days  after its birth was also seized
with violent pains and  convulsions, and flow  of blood from the va-
gina, from which, shortly after, there was expelled another perfectly
formed  and living female foetus followed by  a placenta!   The
two  infants were  baptised together and  died the  day after.  For
ourselves we conceive this to be scarcely, in any respect, more mar-
vellous than the detritus of a foetus within the scrotum of a healthy
full grown  living male subject.
   The fatal influence also which the removal of this apparently  inert
and insensible mass, had upon the individual in  whom it lived,  goes
still farther to corroborate, that there then existed and had previously
been established a primordial and indissoluble organic union between
both.   The result also would go to show, though the  cases are not
parallel, that an attempt to divide asunder the vinculum which unites
the Siamese twins would, as many surgeons  have conjectured, spee-
dily prove fatal to one or both.
   Scrotal Tumor.—An irregular, oblong, lobulated, adipose  tumor,
eight inches by six in dimensions, situated in  the  left side of the scro-
tum  of a patient forty-three years of age, and which first made  its
appearance in 1842, and the true diagnosis of which from hernia em-
barrassed even MM. Lawrence, Brodie  and  Travers, was  removed
in April, 1845, by Mr. Lawrence with perfect success.  Mr. Curling,
in remarking upon this case and the deception caused by the swelling
of the tumor just before stool and  when the patient  was in an erect 
436          NEW ELEMENTS OF  OPERATIVE SURGERY.
position, explains  it very naturally by the accumulation of blood in
the parts, from the interruption  made by the foeces in the colon to
the return of the sanguineous circulation from  the  tumor and  sper-
matic veins. (Provincial Med. and Surg. Journ., June 25,1845.) T.]

              Article V.—Diseases of the  Penis.

                        § I.—Phymosis.

  A.  Varieties.—The contraction of the prepuce is a disease which
presents itself to the operator under three principal forms: 1st. The
congenital  variety is in  no other way annoying except in presenting
an obstacle to the flow of the urine, or in occasioning, in adult age, the
pains which result from  it in the efforts of coition ; 2d.  That which is
the effect of inflammation, more or less acute,  may give rise to acci-
dents of quite a severe character; 3d.  In the accidental but chronic
form, the entire prepuce may be indurated and  thickened  in such
manner as  to form a hard  indistensible and, as it were, lardaceous
or elephantine shell, which encases and goes beyond the entire glans
penis.
  I. If the congenital phymosis is caused, particularly as happens in
infants, by the excessive elongation of the  integuments, no other
operation is required than that which is known and performed in the
East by the Jews, according to the precepts of their  religion, under
the name of circumcision, and which M.  Brueck, (Journ.  Univers.
des Sc. Med., t. VIII., p. 185,) does  not hesitate also  to recommend
as a preventive of phymosis and chancres!
  II.  Nor does that form of phymosis which is produced by an acute
inflammation, chancres,  venereal  lesions or any other cause, require
the employment of instruments, except it should constitute too great
a difficulty in the  treatment of  the principal  malady,  or that we
should have found ourselves unable to subdue it by means of topical
applications, injections and other appropriate remedies.
  III.  The third variety has been but rarely met with.  When it is
ancient and has proceeded to such degree as to render the emission of
the urine difficult, it admits scarcely of any other remedy than the
division of the contracted periphery.   If it were only  an elephantine
transformation, compression perhaps might be  found  to answer, and
a patient whom I  treated in this manner did  exceedingly well.   In
other cases we are obliged to extirpate the entire shell.  Under such
circumstances M.  Kerst  first  divides  the  frenum ;  he then, by
means of two vertical  incisions, lays  open the  prepuce into two
halves, which he  removes  separately in the following manner : the
prepuce is  to be divided by the bistoury down  to its inner layer; the
surgeon, then drawing  upon this, incises it with the scissors as near
as possible to the  root of the glans penis.   By dividing in this man-
ner the tegumentary layers of the prepuce to  an unequal extent, we
avoid the constant tendency which the inner one has to become turn-
ed  outwards when both  are cut to the same point.
   B.  Operation.—It is to be remarked, moreover, that in  performing
the  operation upon a  prepuce  having ulcerations upon its inner
surface,  we incur the  risk  o* having the wound   itself undergo 
                     DISEASES OF THE  PENIS.         .         437

ulceration, and that in such  circumstances we must not  omit the
employment of anti-syphilitic  remedies both local and general.
  I.  The Dorsal Incision.—The operation for phymosis, which is one
of the most simple in surgery, requires no other articles than a straight
bistoury, scissors, a director without any lip, a dressing and a ligature
forceps, a plumasseau of lint besmeared with cerate, two or three fine
compresses and a narrow band  about a yard long.  The concealed
bistoury  of Bienaise, which was employed by Lapeyronie, as well as
other special instruments designed for this purpose, are wholly useless.
  a. Ordinary Process.—The patient is seated on a chair,  unless he
should prefer the bed.  The surgeon  glides the director under the
prepuce as far down as to the  root of the glans penis.  The assistant
who holds the penis, takes care at the  same time to keep the director
and  skin  properly adjusted to  each  other.  The bistoury, guided
upon the groove of the director,  reaches to the base of the cutaneous
fold.   The point  of the  instrument  is  then   immediately turned
towards the skin, in order to perforate the prepuce from within out-
wards, and then  to  incise it  rapidly  from behind forwards.  The
incision,  by means of a puncture from the deep-seated parts towards
the skin, possesses  this advantage, that  the patient in drawing back
terminates the operation, so to  speak, himself,  instead of disturbing
the operator.
  b. Some persons, in order to  dispense with the director,  introduce
the bistoury after the recommendation of Sabatier, flatwise between
the glans penis and its envelope, proceeding in other respects in the
manner just described.   There are others also, who in order to avoid
wounding the  parts upon  which we  wish to glide  the  instrument,
place a small ball of wax besmeared with oil or cerate, on the point
of the  instrument, which  latter having once reached the bottom of the
cul de sac, passes without difficulty through the wax at the same time
that it perforates the tissues which are to be divided.
  c. The scissors are scarcely  any longer ever used at present.  Being
compelled to act upon parts that are very soft, and difficult to be held
steady, they rarely make a sufficient division at the first  cut.   They
are  consequently  not  employed except for  regularizing  the incision
made  by  the bistoury, when this incision has not divided  uniformly
both layers of the prepuce,  or when we wish to give it a some-
what  greater length.
  d. Some surgeons consider it advisable  to  adopt other and still
more  minute  precautions,  with  the view of preventing  the wound
from  extending too far  either inwards or outwards.   M. Ricord,
(Journ. Hebdom., t. XI., p. 297,) for example, recommends,  when
we do not decide upon circumcision, that the tegumentary fold should
be seized  by means of two, or  even  three dressing-forceps, from its
free border down  to its root, upon three different points, in such
manner as to enable us to stretch it sufficiently to allow the bis-
toury  or  scissors to cut  through it without the fear of  making the
layers which compose it slip  over each other.   Besides the embar-
rassment  of  so  great a  multiplicity of instruments, which exact,
moreover, an  equal number of assistants, this  method  would have
the  disadvantage  of being but rarely applicable;  when  the prepuce
is so contracted as to require the operation for phymosis, it would 
438           NEW ELEMENTS OF OPERATIVE SURGERY.
not admit  of the simultaneous employment of three forceps  and a
cutting instrument.
   e. M.  Lisfranc, (Margot,  Revue  Med., 1838, t. I.,) in order to
avoid the angular projections of the wound, proposes that we should
confine ourselves to the excision  of a  semilunar flap, from the an-
tero-dorsal border of the part, which excision he perforins by means
of scissors, curved  on their  flat, and which he repeats on several
points of the membranous  contour, should  the first notch not seem
to be sufficient.
  f. This process might be replaced by the removal of a triangular
flap from the contracted circle, should an actual loss of substance be
deemed advantageous.  This last mode of excision, moreover, would
in some  respects become "indispensable if we had  to operate for a
phymosis from chronic induration, as I have done in one instance at
the hospital of St. Antoine, in a man who  had the entire sheath of
the glans penis transformed into an  actual fibro-cartilaginous shell.
M. Roux has seen a similar case.   A stony cap (calotte) lined the
interior of a  prepuce thus  degenerated in the patient  of M. Sper,
(Lancette Fran$., t. I., p. 377.)  In such cases it might  be even ad-
vantageous to adopt the process  of  M. Kerst, and to  extirpate the
prepuce  entire.   I would, nevertheless, remark  that a  patient who
was in the same state  as  mine, and whom  M. Voisin, (These, No.
205, Paris, 1832,) operated  upon, died thirty  hours  afterwards  from
urinary resorption.  But in another case the same practitioner obtained
complete success, though the tumor had become  prolonged under the
urethra, (Gaz. Med., 1839, p. 89.)  A case of elephantine phymosis
successfully operated upon  by means of the dorsal incision, occurred
in 1838  in the hospital service of M.  Liston, (Encyclogr.  des Sc.
Med.,  1839, p. 234.)
  II.  The Urethral Incision.—In adopting  the dorsal region for the
incision in phymosis, we  incur the risk of the sides of the wound
being drawn back and separated apart, so  as to give rise to the for-
mation of a border which is sometimes very annoying.   The exci-
sion of the free angles of the division, is but a very imperfect rem-
edy for the inconvenience in question.
  a. The process devised by Guillemeau, (De la Nourrit. de VEnfan,
chap, xxxvii., p. 438, in  8°,) who had a special  instrument for this
purpose,  or the method of  AI. Cloquet, (Bull, de  Fer., t. VIII.,  p.
206.) is infinitely less calculated  to produce this difficulty.  It  con-
sists in performing the operation at the lower part of the prepuce.
The bistoury is to be directed upon one  of  the sides of the frenum*
which  itself is to be divided  immediately afterwards, should it  ap-
pear to  be too much prolonged  forward.  Besides that  there  are
fewer vessels  in this direction than in the first, the wound  in conse-
quence of the retraction of its lips, becomes transversal only, and thus
po-operates exclusively in continuity  with the opening, which it was
our intention to enlarge, without leaving, as in the preceding case a
deformity almost as embarrassing as the original disease.  It would
appear, moreover, that the  ancients adopted the same course  for
Celsus, in speaking of phymosis says, "  ....   subter a summd
or ct cutis inciditur rectd lined usque ad frenum, atque ita superius
tergus relaxatum cedere  retro potest."   I have frequently used this 
DISEASES  OF THE PENIS.
439
process, and everything induces me to believe that it will ultimately
be substituted for the other.
  b. The excision of the  frenum by means of a V section from the
prepuce, as proposed by Taxil, (Arch. Gen. de Mid., 2e ser.,' t. XL,
p. 230,) is referable to the same  principle.
  c Instead of placing the incision upon  the  median  line, either
above or below, we are sometimes obliged by  the presence of vene-
real ulcers or tubercles, to make it on the side, or even on both sides
of the organ; but before this could be necessary, the prepuce must
have been profoundly altered at the part which, under such circum-
stances  would become the place of necessity, for these lateral  divi-
sions usually produce, whatever M. Malapert, who has endeavored
to popularize this process says to  the contrary, a very great degree
of deformity.
  d. Process of M. Begin.—M. Begin having grasped the prepuce
with the forefinger and thumb  of the left  hand, makes,  by introdu-
cing into this opening one of the branches of a scissors curved flat-
wise, an oblique incision from  the  part nearest to the frenum to the
middle of its dorsal  surface; then bringing the  instrument back to
this  point, he carries it as far as on the opposite side.  The integu-
ments being afterwards pushed back, the inner lining of the prepuce,
which remains upon the glans  penis, is incised upon the median line
as far as to the fold which forms its  base.   If the preputial ring is
too  narrow to  allow of the introduction of the scissors, M. Begin,
(Elem.  de Chir., 2nd edit., t. I., p. 550,)  uses a bistoury surmounted
with a ball of wax and lays open the  prepuce  from about the middle
point of its length up to its free border.   The  two  angles of the
wound are then trimmed with the scissors, and the inner membrane
is longitudinally incised in a third stage of the operation down to
the  base of the glans.   No accident ensues  from this operation and
its result, according to the author, is to leave no deformity in the part.
  e.  In  whatever way we proceed, it is  possible and even very ad-
vantageous when the coarctation exists to a great degree, to plunge
the  point of the bistoury guided  upon the sound through  the skin, or
from without inwards as is recommended by MM.  Heurtaut (These
de Paris, 1811) and Tavernier, instead of making the puncture from
the  interior to the exterior.   A good rule also, laid down by M. Tav-
ernier, (Bull, de Therap., t. I., p. 147,)  with  the view of not deceiv-
ing ourselves in respect to the relative extent  of the incision of the
organic  tissues, is the following: the  sound being properly placed,
its beak is to be moderately pushed forward ; the surgeon  then draws
back the  integuments until the rosy  border  of the mucous lining
shows itself.  The parts being held in this manner by an assistant or
the  surgeon himself, we shall be certain  that the instrument perfo-
rating by a puncture either from the skin towards the sound or from
the  sound towards the skin, and brought forward from the root of the
prepuce to its free border, will make a section as neat and as uniform
as possible.   [This  process I  have  successfully  followed in about
20 cases.   T.]
  /. As soon as the operation is terminated the  cutaneous  fold
mounts  upwards behind the gland.  A plumasseau is  applied upon
the  wound, which is to be surrounded with one fine and two long 
440           NEW ELEMENTS  OF OPERATIVE  SURGERY.
                                                  *
compresses, or by a Maltese cross.   To terminate the dressing, the
extremity of the  bandage is to be brought to the root of the penis,
thence carried forward by circular  turns to  the  anterior extremity
of this organ  and afterwards  carried back again where  it is to be
finally attached.  A suspensory previously applied, would enable us
to keep up this small dressing 'much better still, and would render it
less liable to be displaced.  Finally it is advisable to make use of one
or two  turns  of  bandage or a cravat passed around  the loins, by
which means we  are  enabled  to keep all the  parts turned back in
front of the pubes.  The dressing is not to be renewed until the end
of two or three days, unless it has become loose, and as soon as the
solution of continuity begins to suppurate it is reduced, in fact, to so
simple an affair that it is useless to speak of it more in detail.
  g. In order that the wound  may remain as narrow as  possible in
the antero-posterior direction, and  that it may not be too long in
closing, there will  be  an advantage  especially to begin at the first
dressing  in placing the turns of  the  bandage  upon  the body of the
penis, by proceeding from behind forwards, and then in making use,
as M. Tavemier recommends, of a Maltese cross, having a hole in its
middle portion, in order that it  may leave the  glans penis  uncovered,
while at  the  same time it pushes the divided  prepuce from before
backwards.   The dressing being thus adjusted, is found to be  more
solid and all the tissues to be pushed against  each other,  in place of
having a tendency to be separated  apart,  as frequently happens
when we do not  adopt  this  precaution.  At  a subsequent period  I
have  found  it  advantageous  to draw forward the callous border
which the borders  of the  division  will  form for a considerable
length of time, in order to make some  compression upon it and to
favor its resolution.
  h.  Process of  the Author.—The  following process has afforded
me excellent results.   I introduce  three or  four nooses of thread
on each side of the frenum, at  three lines apart from each other, and
then immediately detach the frenum with a  good  pair of scissors.
The point of a bistoury plunged in at the root of this wound on the
median line, then lays open the prepuce, as in the  process of M. Clo-
quet.   Having divided the nooses of thread at their middle portion,
I instantly knot them separately, and in this manner obtain the same
number  of points of  suture, which  immediately  close up the two
sides of the wound.  In this manner there is no need of any dressing.
and the cure may take place in three or four days.

                      § II.—Paraphymosis.

  A.  If compresses wet with cold water, ox containing ice, which pos-
sess the virtue, by diminishing  the afflux of fluids, of reducing the size
of the corpora cavernosa, of putting a term to the strangulation, and
enabling us to bring  the  prepuce  forward, should not &be found to
answer or cannot be employed, and should the inflammation or pain-
ful condition of the parts  present in other respects no objections, we
have  still another resource to make trial of before proceeding to the
operation, properly so called, which is used in paraphymosis.°
  B.  This resource is compression.   Some do this in the same way 
DISEASES  OF THE PENIS.
441
 as in applying  a roller bandage, the pressure  made by which  is
 gradually augmented until the reduction  of the glans penis  can be
 effected;  others make use of the fingers, and in such  manner that in
 most cases we are enabled to  relieve the patient immediately.  The
 surgeon then grasps the penis  with the fore and middle finger of each
 hand, crossing them behind the engorged border; his  two thumbs
 remaining free, are to rest against the sides of the glans penis, in such
 manner that by  acting in concert with the fingers, but in an inverse
 direction, they may crowd the glans  backwards, while  the prepuce
 is brought forcibly forwards  as  if for the purpose of covering the
 thumbs, which will then be found to be lodged in its interior. In order
 that the fingers may not slip upcn the skin, it is advisable to separate
 them from it by means of a fine piece of linen, which  has the  advan-
 tage, also, of rendering the operation a little less painful.  We should
 be wrong to reject this process merely because the disease has ex-
 isted for 12 or 15 hours, and that the  parts have already become in-
 flamed and painful.  I have made use of it in several  instances with
 entire success at the expiration of 24 hours, or of 3 or 5 days with-
 out any inconveniences on that account, although the front part of
 the penis was extremely sensitive, and that there were many chinks
 upon the sides of the preputial border.  It is an operation calculated
 to succeed in the majority of  cases if it is well performed, and the
 steps of which it is unnecessary to point out more in  detail to those
 persons who are sufficiently well instructed to know how  to execute
 it in the manner required.
  C. In case however it should  not answer the expectations of the
 surgeon, and that circular compression should not be practicable, we
 should proceed then to the cutting instrument.
  I.  While an assistant stretches the penis at its two extremities and
gives a moderate curvature to its lower, side, the operator glides  a
narrow bistoury  flatwise between the dorsal surface of the glans
penis or corpora cavernosa, and its envelopes as far  as to the point
of strangulation, then  turns the edge of the instrument  upwards to-
wards the skin, if he is certain of having  penetrated  underneath the
 constriction, or in the contrary  case, towards the side of the penis, and
then immediately makes the incision, depressing the wrist  in the first
 case, and raising it a little  in the second.  If a first incision should not
 appear to answer, we immediately make one or two more in the
 same manner.
  II. Processes of the author.—In place of digging away in this man-
ner in the tissues in order to reach down to the  bridle, and instead
of first incising the skin posteriorly, and inserting through that open-
ing a grooved director to guide the bistoury under the strangulation,
as recommended by Richter, would it not be better to make the in-
cision directly on its external surface ?   I  know of no circumstances
scarcely which could render an incision of this kind wholly imprac-
ticable.   By causing the skin to  be  drawn back towards  the  pubis,
while an assistant endeavors to reverse the diseased border in front
we generally  succeed  in exposing to view the  base of the circle
which causes  the accident.  Nothing is  then easier  than to  direct
perpendicularly upon this  border the point of a straight bistoury held
as a writing pen, and to make on one  or several points, by means of
  vol. in.                       56 
 442           NEW ELEMENTS OF OPERATIVE SURGERY.

 this  instrument,  small incisions wnich  we may carry to  any depth
 required without incurring the risk of making any mistake as in the
 other method.   I give  the  preference to this process, and I have
 found it to succeed so well, even on a very young  child, in whom
 the paraphymosis had existed for the space of three days, and upon
 all those adults in whom I could not reduce the glans  penis by means
 of the  fingers and thumbs, that I can scarcely conceive any circum-
 stances in which the ordinary process would be considered indispen-
 sable.  If a straight cataract needle, or  my opthalmoxist, or the small
 tenotome of M.  Bouvier, were glided from before  backwards under
 the prepuce, or inserted by puncture under  the  bridle from behind
 forwards, they would render the operation still more simple and cer-
 tain, and less painful.  A  small quantity of lint besmeared with ce-
 rate, lotions of marshmallow water, topical emollients, and the most
 simple containing  means, are the  only auxiliary  treatment  subse-
 quently required by this small operation, which could not  be attend-
 ed with any inconvenience unless we had wounded the corpora ca-
 vernosa by largely laying open their fibrous envelope, or had divided
 the principal arteries of the penis;  these  accidents, however, would
 appear to be of very little importance.

               § III.—Strangulation of the Penis.

  Since Morand drew attention to this subject, all practitioners have
 related cases of individuals who mechanically, and from depravity, or
 inadvertence, have got their penis incarcerated in certain cords or rings
 from which they could not afterwards withdraw it.  This sometimes has
 been produced by a circle or ring of iron, copper, silver, gold, or any
 metallic cylinder whatever;  at other times merely  by a packthread
 or common thread, &c, or by the socket of a candlestick, as has
 been seen by Dupuytren.  Sometimes, finally, it has been effected by
 means of a steel ellipse, known under  the name of  briquet, which
 persons have imprudently placed around their penis, occasionally em-
 bracing with  it even the scrotum also.   The parts soon react  upon
 such obstructions, which latter subsequently become concealed at the
 bottom of a groove of more or less  depth, and consequently by the
 swelling which they occasion speedily bring  about  a  perforation of
 the urethra, or of the fibrous envelope of the corpora cavernosa, even
 if they should not go to the extent of producing a gangrene of these
 parts.  Bands of thread, cord, or ribbon, will never produce any se-
 rious embarrassment to a surgeon ;  the point of a bistoury or a sharp-
 pointed scissors, will always promptly divide them, without any great
 difficulty. The same remark nearly, would apply to a circle of wil-
 low,  bulrush, or wood.   To divide  a ring of ebony,  ivory, or horn,
 it would  become necessary to use a very  strong pair  of scissors  or
 cutting pliers ; while for metallic bodies, the  file  or saw  would fre-
quently become  indispensable.  In  such  cases, a  cutting diamond
 would be a valuable resource if it could be commanded.0 Unless it
should  have a great degree  of thickness,rthe  hardest circle would
 probably yield to the  application of two small hand-vices if  it were
practicable to grasp it.   Should there be  too great a degree of en-
gorgement, this is to be in the first  place diminished by means  of 
DISEASES OF THE  PENIS.
443
bird-peck punctures and scarifications.  Afterwards, the edges of the
groove are to be separated as much as  possible, in  order to insert
when it can be done, a piece of wood, metal or linen, under the con-
stricting body,  to protect the parts against the action  of the instru-
ments.   Moreover, the saw and file should be directed almost trans-
versely to the penis, much more than in the direction of its length, while
the employment of the other means will be sufficiently understood in
themselves without the necessity of entering into further details.  A
boy 7 years of age, in order to prevent his any more  wetting his bed,
undertook to tie the middle of his penis with a thread.  The mother,
who did not find it out until the 7th day, brought him to consult me
at the Hospital.  The skin cut through by the thread, had cicatrized
over it, and the ligature was no longer  visible except by the extremi-
ties of its knot.  After having divided it, I effected its extraction and
on the following day no further  difficulties remained.  The urethra
had not been divided.

                 § IV.—Division of the Frenum.

   The frenum  of the penis, like that of the tongue, is sometimes a
good deal too much prolonged in front.  From whence it results that
in certain persons, the penis during erection is obliged to becomo
curved downwards in  such manner as to  render copulation painful,
and ejaculation difficult.   The remedy for this peculiarity is so easy
of application that any person may use it.  In the first place, the ab-
normal fold frequently tears of itself during the efforts of coition ; if
it  resists this, it is  to be divided by the  scissors or  bistoury.  The
glans penis being properly raised up by  an assistant or the patient,
the surgeon has nothing more to do than to draw the prepuce down-
wards, and if he uses the scissors, to  divide the bridle from before
backwards, and as much of it as possible with a single cut.  If the
bistoury is preferred, it is a matter  of indifference almost whether we
transfix the frenum at its base to divide it from behind forwards,  or
merely incise it from the free border to  its adhesions.   In every case,
we should while separating it, graze the glans penis,  in order that no
rugosity  may remain on this part after  the cure.  Its destruction  by
means of caustics,  nitrate of silver, &c, formerly employed, and even
still at the present day by some  persons, would  not  be made use  of
unless the patient  had too great a dread of the cutting instrument.
Though it may be scarcely necessary to  employ any dressing what-
ever, we should, if the individual were very irritable, or too timid, cover
this small wound with linen besmeared with cerate, and  then  with
lint over this.   We must take care, moreover, not to leave the pre-
puce too long a time in the same place, provided it continues to cover
the glans.  Otherwise the parts might become agglutinated together,
and the operation prove a failure.

         § V.—Adhesion of the prepuce  to the glans penis.

   The inner surface of the prepuce sometimes adheres very closely
to the glans.   When this infirmity is  not accompanied with co-
arctation, it does not in general  involve any  particular inconve- 
444
NEW ELEMENTS OF OPERATIVE  SURGERY.
nience, so that it would be imprudent  to  attempt tc remove it  by
means  of  an operation.    Nevertheless, if as  in instances that
have been related, it should render coition  impossible, and  the pei-
son  should wish at any hazard to attempt its  cure, the following
is the mode in  which we should proceed.  After having detached
the  prepuce  below to a  sufficient extent to  allow  of its  longi-
tudinal  division, the surgeon should dissect it little by little around
its whole circumference, as far as to the union of the glans with the
body of the penis.   To prevent the parts  from coming again  in
contact and reagglutinating as  before, it  would  be  necessary  to
keep the skin drawn back towards the pubis, and the wound covered
with a perforated linen spread with cerate,  and  supported by lint, a
compress, and a  bandage ; finally, all the proper means should be had
recourse to, to compel the bleeding surfaces to cicatrize separately.
J. L. Petit has justly remarked  that the destruction of these  adhe-
sions is neither  an easy matter, or unattended  with pain.   Unless
they should  be complicated with phymosis, it would  even be  better
perhaps where they include the whole  circumference of the glans
penis, not to meddle with them.  When, on the contrary, they make
only a simple  bridle, or occupy only one of the regions of the  or-
gan, the deviation which they cause in the penis during erection, and
the greater facility with which we may destroy them, authorize us in
not respecting them.  M. Laugier, (Arch. Gen. de Med., t. XXVII.,
p. 5,) has shown that in children, where from the phymosis they cannot
be generally recognized, or where at least we cannot ascertain their
character, amputation of the prepuce or circumcision is the most ra-
tional course to be adopted, provided, however, that the greater por-
tion of the glans  penis would be enabled to continue uncovered after
this excision.

               § VI.—Destruction of the Prepuce.

  The prepuce in place of being too long and adherent to the glans,
may be too short.  Celsus, who had already devised a  mode of de-
stroying this defect of conformation, advises that we should  make
on the body of the penis a circular division  of the skin at a certain
distance from  the glans, then to draw the integuments forwards and
fix  them by means of threads  beyond the free  extremity  of the
organ.  At the present day we know, and  can no longer  doubt, that
an operation of this kind is unnecessary, and that the cicatrix scarce-
ly ever fails to draw the skin gradually backwards again, and thus
re-establish  the  defect in  its original condition;  but it is probable
that we should succeed  better by detaching the anterior portion of
the penis, from its envelopes to the extent of one or two inches  in
such manner, as  to be enabled to bring them as far as to the front'of
the meatus  urinarius, under the form of an  artificial sheath.   Only
we should then have to adopt  precautions to prevent the adhesions
of this new encasement from being prolonged too far upon the body  of
the glans penis itself.   If the prepuce had lost only a small quantity
of its periphery, and it should  be found impossible to  remove this
notch in proceeding in the manner of harelip, we should have  to
dissect to a greater or less extent the two sides of the division, in or- 
DISEASES  OF THE PENIS.                  445
der afterwards, when we had abraded its edges, to approximate and
unite them by suture.  In conclusion, it is  evident that posdeplasty
would present in fact  as many modifications  as cheiloplasty.  M.
Dieffenbach, moreover, has shown that  Sabatier as well as  J. L.
Petit, were under an error in proscribing as impracticable those dif-
ferent species of  restorations applicable to the virile member.  (See
Anaplasty, Vol. I.)

                § VII.—Amputation of  the Penis.

   A. From the mobility and the extreme distensibility of the envel-
opes of the penis, it will happen that tumors of the prepuce for ex-
ample, will gradually push back the glans  and corpora cavernosa in
such  manner  as  to appear to occupy the  place of the  body of the
penis itself, when, in fact, there  are no  other than its coverings
that are affected; from  this, without doubt, originated  the error of
certain ancient authors, who  imagined that the penis was capable of
being reproduced, and that it has been seen to grow again, after hav-
ing been amputated.  We may, in fact, remove a very considerable
extent of parts and nevertheless not reach  as far back as the meatus
urinarius.   The tissues which  have been  in this manner crowded
forward  by the tumor or the  swelling, are elongated in  such cases to
so great an extent as to impose readily upon those who are already
predisposed to error.  Cancer  is  not the  only malady which may
cause this  illusion, for all other kinds of  degenerescences are calcu-
lated  to  produce  the  same effect.   Even acute inflammations have
sometimes  given  rise to this deception.   In 1824 there was admitted
into the hospital of Perfectionnement, a robust man about forty years
of age, in whom  the penis, which was enormously swollen, became
gangrenous, in twenty-four hours, down to  two inches from its root.
Precautions were adopted to  save what might remain of the glans or
of the corpora cavernosa in the midst of this putrilage, but they were
found, intact,  behind  the sphacelus,  and were without  any  lesion
except some slight excoriations on  their front part.
  B. Amputation of the penis may be either partial or total; partial
whenever the  cancer does not occupy its  entire substance, and in the
contrary case  total.  Those descriptions of cancer of the penis which
commence  on  the  skin, either at the prepuce or elsewhere, do not in
general  reach  to  its fibrous  envelope or spongy tissue  until after
the lapse of a  very long  period of time;  we  should therefore  com-
mence their extirpation  in the same  way as if to preserve the prin-
cipal organ, but so as to  keep  in  view nevertheless our power to
sacrifice it  when it shall  be found  to be actually altered.  The pre-
cept  of removing only the degenerated tissues, one which so  many
ancient  authors insisted  upon, and to which Callisen so frequently
reverts when speaking of  operations  to be performed on the genital
organs, has been  too  frequently overlooked.  The  suggestion also
made by M. Earle, (PI. Portal, Clin.  Chir., t. I., p.  57,  1836,) that
we should  remove only the cutaneous or superficial layers when the
cancer of the penis does  not appear to have involved the cavernous
tissue, deserves to be adopted.  We should rigorously adhere to  it
therefore especially in cases where, like that related by M. Gendrin, 
446          NEW ELEMENTS OF OPERATIVE  SURGERY.
 there was a well-defined hematic tumor, or one that was sebaceous
 or lipomatous, or any whatever that was cutaneous or sub-cutaneous,
 as has frequently occurred to me in my practice.
   C. Besides the peculiarities connected with the envelopes of the
 virile member, amputation of this organ requires that we  should  not
 lose sight of the arrangement of its own appropriate elements.   The
 fibrous encasement which forms  its  covering, and the spongy tissue
 whose meshes  all communicate with each  other, cause it to be
 elongated or shortened immediately after the operation, according as
 the tumor should  have previously crowded it back or drawn it for-
 ward.   The cavernous arteries enclosed in its interior, one on each
 side, being but  slightly  adherent, protrude  at the  surface  of  the
 wound if the stump has retracted to a considerable degree; on  the
 contrary they will appear to  be embedded  in its  tissues if it  has
 undergone an elongation.  The urethra being applied  against its
 lower surface and also in immediate contact with the skin, presents
 moreover this remarkable peculiarity, that its free wall attaches itself
with great facility to that which is adherent; so that it almost always
 conceals itself at the circumference of the wound immediately after
the amputation.    The osseous septum noticed between the corpora
cavernosa  by M. McLelland,  (The Lancet, vol.  I., p. 714, 1828;
Arch. Gen. de  Med., t.  XVII., p.  272; Journ. des Prog.,  t.  IX.,
 p.  243,)  could not have been extirpated without compromising  the
 life of the patient  or the functions of the penis.  I refused to operate
 in  any manner whatever in a patient who had this singular deformity,
 and  in another in whom  an osseous prolongation, fifteen  lines long,
 was  sent out from the pubis on the left side of the penis.
   I.  Ligature.—The fear of hemorrhage  induced  some ancient  au-
 thors not to make use of the cutting instrument to amputate the penis,
 which they thought it more advisable to strangulate  by means of a
 ligature.  Ruysch cites a successful result obtained by him in this
 manner.   Nor have  Heister, Bertrandi, M. Graefe (Michaelis, Bull.
 de Fer., t. XX., p. 210)  and  M. Binet (Revue Med., 1828, t. III., p.
 70) thought this  method  unworthy of employment.  To  perform it
 we should at least previously introduce into the bladder  a catheter to
 prevent the ligature from closing up the urethra.  If we should have
 any  apprehension of causing too much pain by applying the liga-
 ture immediately upon the skin, nothing would prevent our adopting
 the recommendation which we still find in  Sabatier, to  incise  the
 tegumentary  covering circularly before applying  the  thread ;  but
 this incision, which is as painful as amputation, properly so called, is
 precisely that which deters certain timid patients from undergoing
 excision, and which induces them to prefer strangulation.
   II. Ablation.—The patient is to be placed in a horizontal position.
 An assistant grasps the root of the organ and draws back  the skin to
 a  greater or less  extent towards the pubis, according as the disease
 appears to have drawn it more or less forwards.   The surgeon  im-
 mediately  siezes  the tumor, which has been wrapped in linen, and
 holds it firmly with his left  hand ; with a bistoury or small knife in
 his right hand he then divides with  one cut the body of the penis a
 little beyond the limits of the disease, and perpendicularly and either
 from above downwards or from  below upwards.  A previous divis- 
DISEASES  OF THE PENIS.
447
ion of the skin a little in  advance of the  place where the corpora
cavernosa are to be divided, would add but little to the length of the
operation and would always enable us to adjust the section  of the
penis exactly upon a line with the retracted integuments.   This pro-
cess, therefore, which Boyer recommends, when the disease extends
nearly as far as the scrotum, appears to me to deserve the preference
in all cases.  The arteries which  are to be closed up are sometimes
six in number or even seven, viz., two dorsal, two cavernous, the ex-
tremity of the two superficial arteries  of  the perineum below, and
also those of the septum on the lower median line.   The four princi-
pal ones, however, are the  dorsal and  the cavernous arteries.   The
very loose tissue which encloses the first would render their isola-
tion and  torsion  an easy  matter, should  a  ligature  upon them be
attended with the slightest  inconvenience.   The same remark nearly
would apply to the  second named arteries; but as we are not to
attempt  immediate reunion in a  wound of  this description, it  is  a
matter of very little importance  that the  vessels should be twisted
rather than tied.
   III.  Process of Barthelemy.—Before proceeding to the dressing, a
catheter must be introduced into the urethra. Some persons having
alleged that it would be difficult in some cases to find again the ori-
fice of this canal at the bottom of the wound, a military surgeon, M.
Barthelemy, (Journ. Hebdom.,X. XIII.,  p. 41,) has  proposed that we
should insert the sound before commencing the operation, and to cut
through it at the same time with the  penis, in order that it  might be
thus found placed in  a natural position by the same stroke.  This is a
modification which may be adopted or rejected  almost  indifferently,
did it not incur the risk of  the posterior portion of the tube escaping
into the bladder, or if the  section of this instrument did not render
that of the remainder of the penis somewhat more difficult.   To  a
person possessed of any anatomical  knowledge, the finding  of the
urethra, notwithstanding what M. Barthelemy may say, would never
be a circumstance  of any  great difficulty.   Beclard of Strasbourg,
and MM. Poirson and Bedor, however, have made trial of this pro-
cess with success.
  IV.  The method of M. Schroeger, (Rust's Handb. der Chir., vol.
I., p. 667,) which consists in dividing the penis, layer by layer, from
above downwards, in order to tie the vessels in proportion as they are
cut, is of no value.   The noose of thread passed  through the corpora
cavernosa to prevent their retraction  and tie  the vessels without dan-
ger, as recommended by M. Langenbeck, (Ibid.,) would only be use-
ful in cases where, as in that of M. Hall, (Gaz. Med., 1836, p. 748,)
we were obliged  to  carry the bistoury as far down as under the
pubis.
  V. If the skin should have been crowded back too  far, it  would
of itself spontaneously cover over  the wound, and might in  this man-
ner produce some trouble.   When, on the  contrary, it  has not been
crowded  back  sufficiently, it is seen to retract towards the  pubis,
thus leaving bare the fibrous envelope of the  corpora cavernosa. As
there is  no remedy  to this last inconvenience, and as  in  the other
method we always  have  it in our power to excise the superfluous
portion of integuments, it is in fact better  to draw back the tissues 
448
NEW ELEMENTS OF OPERATIVE SURGERY.
 towards the mons veneris, while we are amputating the penis.  Nor
 would there still, though we were obliged to operate near the pelvis,
 be any argument for giving the preference to the ligature over ex-
 cision.   The vessels at this place cannot present any great degree
 of embarrassment; cauterization, moreover, with the red hot iron, or
 caustics, recommended as a general remedy by  so many  authors,
 would constitute a last resource, which  would be found  sufficient to
 put an end to the hemorrhage.  Compelled by a return of the dis-
 ease to repeat the operation three times, M. Hall, who went as far
 as to the pelvis, nevertheless effected the cure of his patient.   But
 what  shall we  say  to  M.  Ogier, (Gaz.  Med.,  1836, p.  748,)  who
 states that though he amputated the  middle of the body of the penis,
 he nevertheless  reagglutinated  and preserved the glans !
  YI. Dressing.—After the catheter is once fixed in the  urethra,
all that we have to do is to apply a Maltese cross  perforated by this
catheter, over the wound.  Plumasseaux, two long compresses, and a
narrow bandage, which supports them on  the remainder of the penis,
and afterwards  passes once or  twice around the pelvis, constitute all
the pieces of the dressing, unless we should prefer, as after the ope-
ration of phymosis, the employment of  a  suspensory or T bandage,
upon which should be fastened the small bandage or  the extremity
of the two long  compresses which have  been crossed over the bleed-
ing surface. As the  catheter in these cases has no other object than
that of allowing the urine to escape without touching the  wound, and
that of preventing the closing up of the  urethra, we may object  to its
use from the fact that the passage of the urine  over the wound, far
from being injurious,  is  sometimes advantageous.  The proof of this
lies in the fact that  in former times the urine was  frequently em-
 ployed to favor the cure of wounds.
  VII.  It is the opinion of some persons that the urine expelled from
 the bladder would serve  as a sufficient obstacle  to the obliteration
 of the meatus, and moreover from the urethra being  lined by a mu-
 cous membrane, that  there could be little reasonable apprehension of
 its obliteration.   I saw  in 1823 a fact calculated to confirm this  opin-
 ion.   An old man had the  penis amputated by M. Bougon for a can-
 cer ; the catheter was placed and the dressing  applied according to
 the usual rules.   But this man, destitute of every faculty of reason,
 was unwilling at any hazard whatever to  sustain the  slightest dress-
 ing.   On the second  day, he removed  the catheter and  the rest of
 the dressing.  I reapplied them several  times, and was never enabled,
 to induce him to keep them on.  Finally,  it was given up, not  how-
 ever without serious  apprehensions of the  danger that might result
 from this omission.   The wound however cicatrized  regularly, and
 the urethra preserved as good  dimensions as could be desired.
   VIII. A catheter therefore is not  indispensable.—As its presence
 therefore is not  unattended  with inconvenience, we might,  if we
 did not wish to  dispense with it entirely, make use of it, at least
 only  during the  first days, in order to prevent immediate reunion,
 and at the termination  of the treatment  as recommended by Le Dran
 for the purpose of  preventing secondary coarctation.   We might,
 moreover, wholly dispense with it  by adopting the  precaution of
 uniting the mucous membrane of the urethra to the skin by means 
TUMORS  OF THE VULVA.                  449
of three points of suture, according  to the  process which I have
pointed out in speaking of cancer of the lips, and which, according to
M. Rorbye, (communicated by the author, 1838,) he has heard recom-
mended in Germany.
  IX.  I cannot terminate without remarking  that amputation of the
penis,  simple as it appears to be, rarely fails,  notwithstanding, to be
followed by  consequences  of quite a serious character.   Though
patients who undergo this operation almost constantly recover at the
expiration of fifteen, twenty, or thirty days, a considerable portion of
them soon become a prey to the most melancholy reflections, and to
a deep-seated depression of mind that nothing can remove; to such
degree that some ultimately destroy themselves,  while others, in a
number of instances, succumb to their mental despondency at the
very moment when it was least suspected.  If the glans penis alone
is removed, it is shown by a fact  in Scultetus, and another of M.
Buret, that sterility is not the inevitable consequence.  In every other *
other case could the result be other than this ?
                         CHAPTER II.

                THE SEXUAL ORGANS IN WOMAN.

  As abscesses, schirri, loupes,  tumors, and cysts of every descrip-
tion, and  also varices noticed in the labia majora, are to be treated
and operated upon in the same manner, and after the same rules, as
in any other region of the body,  they scarcely require, in this place,
any particular description.  Amputation of the clitoris and exsection
of the nymphae are too seldom required, and of too little importance,
to make it necessary to enter into a detailed separate description of
them.  I shall say  therefore only a few words concerning them.

              Article  I.—Tumors of the Vulva.

  Almost all those tumors which are noticed at the vulva, belong to
the labia majora, labia minora, or clitoris.

             § I.—Labia Majora and Mons Veneris.

  A. Abscesses are frequently developed with great rapidity in the
tissues of the labia  majora.   Their characters consist in making their
appearance rather posteriorly than  in front, of becoming filled with
a pus which readily acquires an  infected odor and dark colored tint,
of being frequently produced, as M. Vidal shows, by small ulcera-
tions  in the vagina,  and of easily taking on afterwards a fistulous
condition when they have been evacuated.  I shall recur to this sub-
ject  under this point of view when treating of fistulas at the margin
of the anus in women; I will merely remark here that these abscesses
should be early and freely opened, on the cutaneous rather than on
  vol.  in.                    57 
450           NEW ELEMENTS  of OPERATIVE SURGER5".

the mucous portion of the labia majora, and in the direction of the
perineum rather than in that of the mons veneris.
  B.  Hematic tumors and sanguineous cysts are also frequently de-
veloped in the tissues of the same organs, either in consequence of falls,
blows, or accidental external violence, or from frictions made during
coition or from the effects of pregnancy, or parturition. Having else-
where treated, (Art des Accouch., t. II., 1835,)  of these tumors under
the title of thrombus of the vulva, and  having related there the prin-
cipal examples of this kind which science possesses, to which might
be  added the six instances related by MM.  Riecke and Elsasser,
(Arch. Gen. de Med., 2e ser., t. V., p.  608,) I  will not dwell  again
upon their history in this place.   Their treatment, moreover, is the
same  as that for hematic tumors  in general, and  it is only in  their
connections with pregnancy or  parturition that they could present
any peculiar features.
  C. Sero-mucous  Cysts.—There exist  in scientific  collections, and
there  are still daily seen in practice, numerous examples of sero-mu-
cous cysts developed  in the tissues of the  labia majora.   These tu-
mors, whose existence has been pointed out by Pottier, (Bonet, Corps
de Med., t. IV., p.  492,) Mauriceau, (Mai.  des Femmes Enceintes,
p. 152,)  Denman,  Watson, and  Davison,  (Denman, Traite des Ac-
couch., 1.1., p. 168,) which I myself have seen in a great number of
instances, and which rarely exceed  the  size of the fist or a pullet's
egg, usually contain a glairy,  mucilaginous, and synovial, or purely
serous matter.  I have already said that they appear to me to  have
been often confounded under the name of hydrocele, with infra-pubic
serous tumors in women.  I  will add  that in most cases we  may
trace  their origin to some ancient injury to the part, or to the conse-
quences of an infiltration or effusion of blood.   It would appear also
that a predisposing cause to these tumors is found  in the species of
bursa-mucosa which  frequently exists in the centre of each labium
majus.  Puncture and iodine injections, when they are of large size
and tense, are the  best means to  apply to  them..  In the contrary
case, it is better to lay them open largely or excise their free portion
to induce the sac to suppurate,  than to treat them by simple incision.
It would be advisable, moreover, to have recourse to the same means
that I have mentioned under the article of sero-mucous cysts in general.
  D.  The mons veneris is liable, like all other regions of the body
in women, to the development  of various  descriptions  of tumors.
M.  Faneau (Precis Med. dlndre et Loire,  &c, 1821,) has met here
with a fibrous mass of the size  of the head, and which he successfully
extirpated.  I have in two instances seen here  an enormous varicose
mass  which ascended up as high as the umbilicus; I have no  need
of remarking that abscesses, thrombi and sanguineous tumors are also
very frequently met with in this region.  Operative  surgery, more-
over,  possesses no peculiar resources which can be enumerated with
any advantage, in treating of these tumors.
  E.  The vulva, which is naturally supplied with numerous ^vessels,
and whose lips, in  old women  especially, are transformed sometimes
into hrge varicose or erectile tumors, is also liable to  all the varieties
of sanguineous fungous tumors from the tenderesj age of childhood.
In a little girl, three years of age, I found the middle third of the left
£| 
TUMORS  OF THE VULVA.
451
labium majus  occupied by  an accurately  defined  arterial  erectile
tumor, which might have been extirpated without any danger.   An
erectile tumor  which was situated upon the left labium majus  of a
woman 29 years  of age, was  successfully extirpated by M. Portal,
(Clin. Chir. &c, pt 142.)   It is readily understood, moreover, that
what has been said of erectile tumors in general, (see Vol. II.,) must
be applicable  in every  respect to erectile tumors  of the vulva in
particular.
  [An Encysted  Tumor in  the left labium majus,  of the size  of a
goose-egg, and which led to the supposition of a hernia, from its dis-
appearing on pressure, was removed by Mr. Syme, (Cormack's Jour-
nal,  Feb., 1846, pp. 83, 84,)  from a woman aged 35, by  a cautious
dissection of the sac, and especially  its  posterior  adhesions.   The
woman speedily recovered.   Mr. Syme had never before met with
an encysted tumor  in the labium, but has  removed one of the size of
a pigeon's egg from the prepuce of the clitoris.  T.]

                  § II.—Tumors of the Clitoris.

  The clitoris, which is a sort of rudimentary penis, is susceptible of
all kinds of degenerations.   The ancients, who frequently amputated
it, had scarcely any other object in view in these cases, than to mode-
rate  the too great  degree  of lasciviousness in women.  Perhaps ex-
cision of the  clitoris considered in this point of view, has been too
positively rejected for more than a century past.  Certain it is, that
a young girl, reduced to marasmus  by masturbation, was radically
cured of her vicious propensities, after M. Robert (communicated by
the author, 1839,) had amputated  her clitoris.   The operation  then
would be so simple, and so entirely exempt from  dangers, that we
should, I think, decide upon it without hesitation.  The clitoris, more-
over, has been frequently amputated  for large  sized tumors.   Wels-
chius (Bonet, t. III., p. 309—t. IV., p. 309,) says that Molinetti extir-
pated one weighing 9 pounds.  Rougemont (Bibl.  Chir.  du Nord,
t. I.,  p. 132,) quotes from Kremer an instance of a clitoris of the size
of three fingers, and which had become transformed into  a sort of
cauliflower, and was amputated with success.  In a woman, who had
menstruated by the urethra, the clitoris,  which  had grown into an
enormous tumor, was also successfully amputated  by M. E. Coste,
(Journ. des Conn. Med., t. III., pp. 205 and 276.)  M. Syme, (Edinb.
Surg, and Med. Journ., vol. 137, p. 387,) who states that he had oc-
casion to excise a tumor of  the clitoris, in a girl 8 years of age, was
also placed under the necessity of extirpating a large cyst, developed
in the same organ in an  adult woman.  But the  most curious case of
this kind is, that described and  figured by M. Schoenfeld, (Encyclog.
des Sc. Med., 1837, p. 188.)    The tumor, which included also the
nymphse, and presented a granular aspect,  weighed 3 ounces.   The
extirpation, which  in other  respects  was easy,  occasioned a hemor-
rhage, which was arrested by cauterization, and the patient was  soon
restored.  A  case  nearly simjjar  had been already related by M.
MftcFarlan, (Arch?  Gin. de Med., 2d ser., t.  II., p. 281.)   What I
have already saici 61" processes jelating to the amputation of the penis,
might be repeated  under  the  head of tumors  of the clitoris.   The 
452
NEW ELEMENTS OF OPERATIVE  SURGERY.
    operation, nevertheless, whatever may be its modification, is  still
    more easy here, and less dangerous than at  the  penis.  As there
    is no large sized artery in the pedicle of the  organ, and no urethra
    to be respected, I see no  reason which could induce us to make
    use  of the ligature rather than the cutting instrument.  By means
    of the bistoury the  tumor may be  removed  in a second of time,
    and should a hemorrhage supervene, it could  be soon put a  stop to
    by the ligature, compression or caustics.   Caustics would not be ad-
    missible  in tumors of the clitoris, except for those degenerescences
    which were flattened, diffused, and destitute of a pedicle, or in  such
    patients as persisted in refusing every other kind of medical resource.
    The ligature in its turn would  not be  applicable except in timid
    persons, or in cases  of tumors with a slender pedicle, or where we
    had  reason to  apprehend the existence  of numerous large sized
    vessels in the  root of the clitoris itself.

           § III.—Tumors of the Nymphce, or Labia Minora.

     Excision of the nymphas,  which  was formerly so frequently  had
    recourse to, is scarcely ever practised  at the present day.   As these
    folds do not acquire large dimensions in our climate  except in rare
    instances, they do not excite the attention of women unless they ac-
    tually become diseased.   Whether the pretended apron of the Hot-
    tentots be nothing more, as M. Larrey maintains (Clin. Chir., t. III.,
    p. 87,) than an elephantine degenerescence of the labia minora, or
    whether it belongs to  another order of hypertrophy or degeneres-
    cence, certain it is, that the wife of a Fellah, whom our celebra-
    ted military surgeon  saw at  Cairo, had  on  the  labia minora an
    elephantine tumor in  every  respect  analogous  to  that which is
    seen in the scrotum.  In the women mentioned  by  Kramer and
    M.  MacFarlan, one of the  labia  minora, or  both, had acquired a
    considerable volume at the  same  time that there  existed as extra-
    ordinary  a development of the clitoris.  M.  Prieger, (Journ.  des
    Conn.  Mid., t. I., p.  90,) who has seen the nymphae acquire an
    enormous volume,  applied the  ligature  to them on  both sides.   One
    of the  tumors became detached on  the  8th day, and the other on
    the 10th.   There supervened an inflammation,  accompanied with de-
    lirium, which  was met by the antiphlogistic treatment, and which
    did not prevent the radical cure of the patient.   Should the nymphae
    be merely hypertrophied. the way would be to excise them either
    with the bistoury or with  a  good pair  of  curved scissors.  A suffi-
    cient number of threads previously passed through their root, would en-
■~   able us after the excision to unite the two borders of the wound by first
$ff  intention, by means of the suture, and in this manner to cure the patient
    operated upon in the space of a week.  The same  process would be
    still applicable, however extensive or of whatever  nature the tumor
    might be, provided the latter comprised the whole length of the fold
    without having its  root too much widened.  Otherwise it would be
    advisable  to divide its pedicle after it had been properly isolated, or
    in other cases to dissect it carefully, and that according to the rales
    laid down in the article on Fibrous Tumors  in general, or on Ele
   phantiasis of the Scrotum. 
TUMORS OF  THE VULVA.
453
                §  IV.—Elephantiasis of the Vulva.

   Fibro-cutaneous, or elephantine tumors of the vulva, appear to be
quite common.  To  the instance cited by M. Larrey, we may add
at the present day, that of M. Gilbert, as related by M. Allard.  In
this case, the tumor,  which was of the size of an ostrich egg, was sit-
uated on the right labium majus.  Another case has been  related by
M. Talrich, (Delpech,  Clin.  Chir., t. I.)   In this the  tumor was 14
inches long, and a foot and a half in circumference, and its extirpa-
tion was performed with entire success.  M. Clot (Journ. Hebd., 1835,
t. II., p. 298,)  has extirpated another of the size of the  head of anew-
born infant, with the same successful result; but a woman who had
one of similar  dimensions removed by M. Green, (Medical Journ. of
Sciences, 1835,—Gaz.  Med., 1836, p. 570,) died a short time after the
operation.   But the most remarkable instance of this kind  of produc-
tion, is that related by M. Rapatel, (Journ. des  Conn. Mid., t. III.,
p. 230.)   This tumor, which was extirpated successfully by this sur-
geon, weighed 17 pounds.  M. Monod, whom I assisted in the opera-
tion, removed  one of the size of the  head of an adult in a  woman 20
years of age, who had  experienced no pain from it, and who soon re-
covered.   I have myself amputated tumors of this description in four
instances, but they were of far less volume.   All of them were pedicu-
lated and pyriform.  One was of the size of an ostrich egg, two that
of a pullet's egg, and  the fourth, which had a thin and  very long
pedicle, was scarcely larger than a nut.  The one I  removed in a
patient of M. Layraud, was on the inner side of the labium majus.  That
of a woman in the Place Maubert, was situated on the outer side of
the fold.   In a patient whom I operated  upon at the Hospital of La
Charite, its  root was imbedded  in  the groove which separates the
labium majus from the breech.  In a fourth case, it appeared to have
been entirely produced by the posterior extremity of the right fold of
the vulva.   In all these cases the operation was extremely simple, as
nothing more was required than to  hold the tumor with  one hand,
while with one cut of  the scissors or bistoury, I divided its pedicle with
the other.  It rarely  happened that there were any more than a  few
drops of blood, or that the patient was even conscious of the operation.
For large sized elephantine tumors,  there would be no other rules to
be observed in the operation than those which are laid down in the
chapter on tumors in  general.  It would be necessary only  that we
should make ourselves  assured before extirpating them,  that there
was no vulval hernia, nor any viscus which had protruded into the tu-
mor through the openings of the pelvis.   A woman, different  from
what exists in  man, having no important part of the  genital organs
externally, is placed  under such anatomical conditions that we may
dissect and boldly remove with free  cuts of the instrument, every de-
scription of  tumor  which is  found  at the vulva, or in the neighbor-
hood of this region.

               § V.—Tumors of the Vaginal Septa.

   The walls of the vagina are  also quite frequently the seat of va-
rious tumors, which are seen sometimes in the interior of the canal 
454
NEW ELEMENTS  OF OPERATIVE SURGERY.
 itself, and at other times have their root in the tissues of the organic
 layers of which  it is composed, or upon its external surface.  Thus
 there have been noticed in  the vagina sanguineous  collections, ab-
 scesses, cysts of every  description, and  schirrous and encephaloid
 tumors.
   A.  One of those  that have  been most anciently known was noticed
 by Pelletan; it was situated  in the  left wall of the vagina.   Dupuy-
 tren  (Lemazurier, Gaz. Med.. 1835. p. 544,) supposed it a hernia, but
 Pelletan, (Arch. Gen. de Med., t. XVII., p. 300,) by  laying it open
 freely, demonstrated that  it  was a cyst.  M. Roux  met with one
' which projected at the same time into the rectum and vagina.   Al-
 though it was  of considerable  size he extirpated it  and cured his
 patient.  In another woman, attended by M. Recamier, (Lancette
 Franc.,  t.  V., p.  92,)  who had a tumor  between  the  rectum and
 upper part of the vagina, it  made  its  way into  and was evacuated
 through this last canal.  The case,  according to every  appearance,
 was one of an hematic  collection.   We are indebted to M. Voilot
 (Gaz. Med., 1835,  p. 702,) for the history  of  a  very  large sized
 tumor, which  was  situated on  the  anterior  wall of  the vagina or
 under the urethra, and which concealed the clitoris, and  contained a
 milky liquid, while at the  same time there was another  tumor situated
 lower down, and which was filled with a dark colored matter.  They
 were successfully excised, and  it would seem, also, that these were
 cases of a degenerate hematic  deposite.  A concrete tumor which was
 situated in the vesico-vaginal  septum, was  successfully extirpated by
 M. A. Berard, (Ibid., p. 384.)   The one treated by M.  Lisfranc
 (Ibid.,—Sonier Moret, Arch., 2e ser., t. VII., p.  243,*) was situated
 in the recto-vaginal septum,  to which it  was adherent  only by a
 pedicle.  Moreover, it must be  that this surgeon operated upon two
 cases, for the patient mentioned in the Gazette was cured, while that
 cited  by M. Moret  died  in consequence of the operation.  A tumor
 of the size of a small egg, which was  situated in the vesico-vaginal
 septum, and which  M. Sanson  (Ibid., p. 543,) removed, was  also a
 cyst of an hematic character.   I operated myself in 1833, at the hos-
 pital of La Pitie, on a woman who had an encephaloid tumor of the
 size of a small  egg about  the middle  of the  recto-vaginal septum, and
 I saw in 1838, at the hospital of La Charite, another woman who
 had one of the size of the fist in the same  place,  or a little nearer to
 the vulva.  I do not speak  here of syphilitic  vegetations, which are
 so frequently seen  at  the entrance of the vagina, nor of hernias
 either of the perineum  or of the labia majora ; but I ought to men-
 tion  that tumors proceeding from the abdomen or pelvis, sometimes
 become lodged to a considerable  depth in the recto-uterine  cul de
 sac, so as to make  a marked prominence  upon  the interior of the
 vagina.  I  have noticed  there a number of times the apex of puru-
 lent  and sanguineous collections, that of serous  cysts and of cysts
 of the ovary and of fecundation, as I have also seen there fibrous
 tumors or the fundus of the uterus itself distended and reversed
  B.  All these tumors  which  I have just spoken of, may lead to em-
 barrassment in respect to  their diagnosis;  before attacking them
 with a cutting  instrument, however,  it is a matter of the greatest im-
 portance to ascertain if they  are altogether local, or if they do not 
TUMORS  OF THE  VULVA.
455
communicate in some way or another with the interior of the peri-
toneal  cavity or rectum posteriorly, or with the  bladder or urethra
in front.   It is  readily understood, in fact, that if the source of the
disease was either an intestinal hernia or that of any other viscus, or
an ulceration or perforation either of the urinary passages or of the
peritoneum  or  intestine, the operation  to  be  performed would  be
very different  from that  for a tumor purely vaginal.  All that  is
necessary, however, to enable us to avoid any error, and to apply to
each disease the operation most suitable to it, is to be apprised be-
forehand of the various lesions which may  take place in that region.
  I. In cases of cysts, whether serous, purulent, or hematic, the ope-
ration  is  easy  and  attended with but  little  danger.  The  process
most advisable  to follow is that of excision.  Having secured the tu-
mor by means  of an erigne, we  extirpate  all its  projecting portion
either  by means of the bistoury or a good pair of scissors.  Injections
which are at first emollient, then detergent,  and afterwards  resol-
vent, will be found sufficient to effect the cleansing and cicatrization
of the surface.  It rarely becomes necessary to  cauterize or to un-
dertake to extirpate the adherent wall of the cyst, which it is better
to leave  in its place, and which ultimately becomes a part of the cor-
responding wall of the organ.
  II.  Should the tumor be very large and  greatly attenuated, or the
matter contained  in it consist of serosity  or  fluid blood, we  might
puncture it, throw up an  iodine injection, and treat it in every re-
spect like a hydrocele.   Should  it on  the contrary  be small, with
thick or well nourished walls, we might undertake its cure by a sim-
ple incision, and treat it as^in ordinary abscess.
  III.  When the  cases under consideration are  those of abscesses
and cysts developed and established in  the recto-vaginal cavity, we
must not forget that arterial branches of considerable size  may pos-
sibly be  found  there, and that by plunging in the  bistoury in this
part, we  moreover necessarily divide the peritoneum.   I have, how-
ever, by plunging a straight bistoury into this cul de sac, cured a
lady of an enormous sanguineous collection, and also a number of
other patients,  who  afterwards discharged a  considerable quantity
of pus through this passage.   I ought to add, however, that in per-
forming the same operation for extra-uterine productions in two dif-
ferent  cases, it did not succeed.   I have moreover, in another work,
treated in detail of this division  of the subject.   (Art des Accouch.,
t. I., 1835, et Diet, de Med., art. Grossesse extra-uterine, 2d edit.)
  C. In respect to solid tumors, I have in several instances met with
those which might have been extracted through the upper part of the
vagina.  I have even been on the point  of undertaking that opera-
tion which has, I believe,  been performed in one or two instances in
France;  but I was ultimately dissuaded from it by the age of the
patient and the size of the tumor.
  I. In the walls of the vagina itself, concrete tumors should be ex-
tirpated  entire  when we  have decided  upon operating upon them.
As  they are situated upon thin irregular septa, their dissection would
be so much the more delicate, inasmuch as we should incur the risk,
should we penetrate into the bladder or rectum, of leaving disgust-
ing fistulas,  which would be found very difficult to cure, at the same 
456
NEW ELEMENTS OF OPERATIVE  SURGERY.
time that we  should  be liable, higher  up,  to perforate  the peri-
toneum,  which  would  also  be attended with its  dangers.   We
should therefore be  careful to protect  ourselves by the necessary
precautions.
  A. In operating on the posterior wall, the woman should be placed
in the same way as for lithotomy.  The surgeon secures the  tumor
at its most elevated portion, by means of an erigne, which he  imme-
diately confides to  an  assistant.  Then introducing his left forefinger
into the rectum, as a guide  and sentinel, he commences by circum-
scribing the mass with an elliptical incision, by means of a straight
bistoury, while the assistant gently draws it forward.   Continuing to
dissect the parts  upon  his finger, he will find himself enabled in this
manner to proceed without danger down to  the mucous membrane
of the intestine, and to separate from  one side to the other, now to
the right and now  to  the left, and from  above downwards, the dis-
eased parts from the sound  tissues. The arteries divided during this
operation are usually so small as not to require either a ligature, tor-
sion or  cauterization.   Gentle tamponing will suffice to check their
hemorrhage.   The dressing is so simple that there is  no  need  of de-
scribing it, and we treat the wound  like all those which  are to be
cicatrized by second intention.
  B. If the tumor were sufficiently movable to enable us, by draw-
ing upon it with one or two erignes, to elongate its base in the form
of a  fold, three ligatures passed through the tissues which compose
it, by means of a curved needle, while the finger protects the inte-
rior of the rectum, would enable us to excise it rapidly in front, and
to reunite the wound immediately by the.suture.
  C. Tumors of the vesico-vaginal septum are still more difficult of
removal than the preceding;  for it is not possible to introduce the
finger into the  urethra or bladder as in the rectum.   It  is better to
place the patient on the belly and on the edge of the bed, with the
thighs flexed, than  upon  her  back or side.  A silver sound is then
introduced into the bladder through the urethra ; the tumor is secured
as in the preceding case and is circumscribed by the same kind of
incision.   But  we  must  afterwards  take care  to  dissect it with
extreme caution and  not penetrate into  the  tissues  of  the vaginal
wall  deeper than is  absolutely necessary.  The sound, which the
assistant causes by an  oscillatory movement to project on the side of
the vagina, serves as a guide to the finger, which should always be
kept at the bottom of the incision to direct the cutting  edge  of the
bistoury.  As  soon as the sides and  apex of  the tumor  are isolated
we  should, while detaching it as  in dissecting flaps  of integuments
from a cyst which  we do not  intend to open, let the danger fall, that
is to say, direct the cutting edge of the instrument rather  towards
the tumor than towards the vesical septum.
  p.' The  previous threads which I have just spoken of could not,
under such circumstances, be  introduced with sufficient security to
authorize  me to venture to recommend  them.   Their employment
however ought to be taken  into consideration should the  tumor com-
nnse the entire thickness of the septum, or should it be decided upon
feat, notwithstanding  the necessity of perforating the bladder, the
iiseased mass must nevertheless be extirpated. 
IMPERFORATION OF  THE VULVA
457
  E.  On the sides of the vagina tumors would not incur the risk of
these  dangers.   In that region there is no important part to wound
so long as it is unnecessary for us to go beyond the thickness of the
canal.  If we were  obliged to  go beyond that point, the operation
would be unattended with danger except in relation to the vessels in
ti^^eighborhood, and to the purulent inflammation which, if once
established in the peri-vaginal tissue, might take on a serious character
by becoming effused into  the  pelvis and peritoneal  cavity.  This
would be an objection here to our  undertaking union by the first in-
tention, and an argument for confining ourselves to simple dressing.

           Article  II.—Imperforation of the Vulva,

   The absence of an opening in the vulva is frequently congenital.
In  some cases it results from acquired diseases, while in  others  it is
owing to the presence of the hymen, which, in place of being a sim-
ple valve, forms  a complete disc, or it  may be owing to adhesions
that have formed between certain parts of the pudendum.  It  may
also happen that the occlusion of the vagina will be prolonged  to a
greater or less height in the pelvis, or even extend as far as the neck
of  the uterus.  So long as the  young girl has not menstruated the
infirmity  in  question cannot,  in  any  manner,  interfere with her
health, while in  an adult woman it would be unattended, but for the
necessity of menstruation, with any other inconvenience than that of
rendering copulation impossible.  Nevertheless if the surgeon is con-
sulted in good season and should judge the operation to be necessary,
he would find an advantage in not waiting for the period of the cata-
menia in order  to perform  it.   In fact when the  operation  is  per-
formed with the view of relieving the  difficulties which may be
caused by the retention of the menstrual fluid, its consequences  gen-
erally will be found to be more serious than in childhood.

                               §1.

  If,  as in the cases noticed by M. Fristo,  (communicated  by the
author, 1838,) those  by M. Coley,  (Arch.  Gen.  de Med., 2e  ser.,
t. II.,  p. 585,) and M. Kulman, (Ibid., t. V., p. 143,)  and those which
I have elsewhere related, (Traite d'Accouch., t. I., p. 108, 2d edit.,)
the vagina is closed  only by a membrane, nothing  more  is required
for its destruction than to plunge through it  the point  of a straight
bistoury, incise it freely from before backwards and then transversely,
and afterwards to excise its four angles.   We then keep the opening
properly distended by means of lint or portions of  sponge shaped in
the form of a tent.   Three young girls whom I treated  in this man-
ner recovered perfectly.   If, before the period of marriage,  the
employment of dilating means is not persevered in  until the cicatri-
zation of the wound is complete, we  would incur the risk of its clos-
ing up again, or at least contracting considerably, as happened in a
young girl six years of age, in  whom one of our confreres confined
himself to a longitudinal division of the hymen, and as happened in one
instance also  to myself.  It  is altogether useless to make at first a
puncture through the membrane by means of the trochar, or to have
  vol.  hi.                   58 
458
NEW ELEMENTS OF OPERATIVE SURGERY.
 recourse to the canulated sound to guide the bistoury, or to any other
 special instrument.   The  perforation  being  made,  the forceps or
 scissors curved flatwise, or even the ordinary bistoury, will always
 be found sufficient for the excision of the flaps.

                              §11.

   In adult age we are not usually called upon to perform this ope-
 ration, except in women who suffer under symptoms to  a certain ex-
 tent similar to those of  pregnancy, and who have the belly volumi-
 nous, &c,  and this in consequence of the catamenia having no ex-
 ternal issue.  If the hymen alone  closes the passage, it is found pro-
 truding and tense, and in some cases even of a bluish or dark tinge,
 caused by the blood which is  endeavoring to force it outwards.   In
 such cases  the opening into it is still less complicated than in the pre-
 ceding circumstances.  Any surgeon may perform it without danger.
 Except that the sudden evacuation  of so large a quantity of liquid,
 and the impossibility for the womb and other organs, that have been
 previously  distended, to  immediately resume their normal position,
 render this  operation in some cases  quite dangerous, from the visce-
 ral inflammations and fever of a bad character, which it might give
 rise to.  Perhaps in such cases it  would be  better not  to make use
 of any effort or pressure to aid the escape of the liquid,  but to aban-
 don its expulsion to the  natural contractility of the  cavities where
 it  has been for so long a time confined.   By this means we leave
no void in  the collection which we have  perforated.  The air can-
not be introduced or become stagnated there, nor react either on
the morbid liquid or walls  of the cyst, by  giving rise  to those
accidents which are  generally imputed to it.   Injections, moreover,
either emollient, detergent,  slightly resolvent, or even antiseptic,
should they be indicated, are not to  be omitted.   Should  there be
ever so little fever, heat, or  pain,  in  the lower belly, the  patient is
immediately to be put upon the severest regimen, and under an anti-
phlogistic treatment, corresponding in energy to the intensity  indica-
ted by the symptoms.   Should the vagina be closed up  to a certain
distance from the external orifice, the operation is naturally attended
with more difficulty ;  in the first place because we can  scarcely as-
 certain beforehand what is the length of the obliterated portion,  un-
 less there be a  sort  of diaphragm or  septum,  which constitutes  the
 obstacle to  be destroyed ; in the second place especiallv, because we
 have to insert the instruments  between  two important  organs, viz.,
the rectum  and the bladder.   Before  commencing, therefore,  we
ought by passing a sound into  the  urethra, and  one  or two  fingers
into the rectum, assure ourselves under such circumstances, that there
is  still remaining a  certain degree  of  thickness  of  tissue between
those organs, that the  womb exists and occupies its natural position,
and that the vagina  m every portion of it is not entirely obliterated;
in  th.s  last  case it might be  hazardous  to undertake its restitution.
Though M. Langenbeck, (Bull, de Fcrr., t. XIII., p. 364,)  in opera-
ting upon  a woman who was  probably destitute of a  uterus, may
have succeeded in rendering the  vagina permeable,  M. MacFarlan,
 (Arch. Gen.de Med., 2e ser., t. II., p. 202,) had  the misfortune to 
IMPERFORATION  OF THE VULVA. '
459
fail completely.   Nevertheless, if the existence of the woman was
endangered by the accumulation of the menstrual fluid, and that there
existed the slightest hope of reaching the uterus by making a passage
between the intestine  and the bladder, we ought, in my  opinion, to
surmount all fears, and not shrink before the difficulties.   Should the
surgeon, in fine,, decide upon operating, the patient is to be placed in
the same way as for lithotomy.   If the difficulty in question is a sep-
tum or diaphragm, it is  to be perforated by a puncture with the bistoury
or trochar.   It will be  an easy matter afterwards to enlarge the open-
ing by repeated incisions, or by a kind of process of debridement with
the bistoury, conducted upon the finger or upon a grooved sound, if not
upon a gorget.  M. G. Baehm, (Arch. Gin. de Med., 2e ser.,  t. XII.,
p. 442,) succeeded in the case of a young woman twenty-six years of
age,  by making use  of a dilating cylinder after the puncture.  A
mulatto in Brazils, (Rev.  Mid., 1832, t. II., p.  473,) was perfectly
cured by means of a  simple incision.   The  patient of M. William,
(Ibid., 1833, t. IV., p.  451,) who cites similar  facts from  Haughton,
Simpson, and Richardson, also got well after passing through divers
accidents.  M.  Fristo, (communicated by  the  author, 1837,) though
obliged to incise in this manner four successive contractions in a wo
man who had an imperforate hymen, was no less fortunate. The mul
tiple debridement also succeeded in the case whose  history  is given b}
M. Bouchacourt, (Bull, de Therap., t. XIV., p. 285.)  While his left
forefinger remains in the rectum, and the  assistant is holding a ca-
theter in the bladder, and taking care to push its beak towards the hy
pogastrium, the surgeon, if operating for the  removal of an obliteration
properly  so called, plunges in the  direction  towards  the vagina,
either a long bistoury  with a narrow blade, or a trochar armed with
its canula.
  The absence of resistance and  the freedom with which he may
turn the point of his instrument in different directions, soon indicate
to him that he has passed  beyond the point of the  disease.  He then
enlarges the  wound a  little throughout  its  whole length while with-
drawing the bistoury, the cutting  edge of  which should even be
directed upon the opposite side and afterwards in  front and behind,
should he feel sufficiently secure of not wounding the surrounding
organs.  When  we have made use of the trochar  and there escapes
through the  canula a  dark  colored viscous liquid, a grooved  sound
may be necessary to enable us to  enlarge  to a sufficient  extent the
perforation we have made.   The introduction of the finger would
enable us to ascertain  if the division  is sufficiently large,  and in the
contrary  case to increase  its extent  in the direction that  may be
deemed most advisable.  Though the vagina, after an operation of
this kind, usually preserves  its permeability, prudence nevertheless
suggests that we should adopt  the necessary precautions to prevent
it from  closing up again.   A tube either  of metal or gum-elastic,
dilated  in the manner of  a  spindle or spread  out externally like  a
funnel in such  manner  as to  be  enabled  of itself to  remain  in
place, and gradually  increased up to a certain size, would, in  my
opinion, be  the  best  means  to  be adopted to  attain this  result,
although meches of lint  or linen daily renewed  after making the
injections, might also answer.  Scientific works contain  so great  a 
460
NEW ELEMENTS OF OPERATIVE  SURGERY.
number of operations of this description, that it would be superflu-
ous at the present time to describe any of them in detail.  Every day
moreover we  find still  published additional cases ; to those which
have been described by MM. Ventura, Cabaret, Delpech, Desgranges,
\Vrilliaume,  Flamant. Renauldin, and  many others  which I have
cited, (Traite  d'Accouch., &c, 1.1., pp. 109,110, 111 and 239; t. II.,
pp. 210, 211, 212,) we may also add those of MM. Keates, (Journ.
des Prog., t. XIII., p. 273,) Jefferson, (Med.-Chir. Review, vol. II., p.
193.) Coste, (Journ. des Conn. Med., t.  III., pp. 105 and 276,) Amus-
sat (Journ. Hebdom., 1834, t. I., p. 70;  Gaz. Med., 1835, p. 785.) and
Fristo, (communicated  by the  author,  1837,) which are the most
remarkable of all.  Though almost all those operations, as well  as
those of MM.  Rossi (Gaz. Med., 1838, p. 682,)  and  Toulmouche, and
those which M.  Roux witnessed in Germany, were followed with
complete success, it is nevertheless not to be forgotten, that  in a  case
related by  Morgagni, the woman died  after the expiration of a few
days, and that in examining the dead body, the bladder was found
extensively laid open, at the same time that one of  the  fallopian
tubes  dilated by the  blood had burst into  the cavity  of the abdo-
men ;  nor must we forget that Dupuytren has frequently seen acci-
dents of an extremely dangerous character result from this operation.
In a patient of M.  Morisson, (Bull,  de Fer.. t. XIII., p. 364,) there
resulted  from  this operation an  abscess in the  iliac fossa which ulti-
mately opened into  the intestine.  The patient  of M. Langenbeck
(Arch. Gen. de Med., 2d ser., t. II., p. 102) died of enteritis.   M. Mac-
Farlan, (Journ. des Prog., t. IV., p. 116,) who,  as I have said, opera-
ted in a case in which there was no uterus, also  lost his patient.  I
will add that M.  Jefferson was obliged  to penetrate in his dissection
to the depth of five inches before finding the retained liquid ;  that in
one of the cases  of M. Fristo he found  it necessary from the vagina
having been transformed into a cord, to reconstruct it entire by dis-
secting upon his  finger the tissues,  layer  by layer ;  and  that M.
Amussat, operating in a case full  as difficult, detached and tore the
laminae of the  recto-vesical septum by  means of  his finger directed
from below upwards, to a much greater extent than he divided them
with a  cutting  instrument.  M. E. Coste went  farther.  The vagina
was opened into the bladder ; having laid open the urethra and after-
wards adjusted a cylinder of lint in the  bottom of the wound on the
side towards the  rectum, he  ultimately constructed there an entirely
new vagina.
   [Vuginal occlusion from traumatic  lesion.—Mr.  J. W. Square,
surgeon of the hospital at Plymouth, (Eng.) was  called to a case of
cicatrized vagina in 1843, aged thirty-four years,  caused, as it would
seem, by the use of the forceps with her first child three months pre-
vious.  The vagina was quite closed at an inch from its orifice, and
emitted a purulent  discharge.  The partition, however,  was pene-
trated  by a probe, and  for weeks bougies, catheters, and sponge
tents were introduced, but produced only intolerable pain.   The sur-
geon determined upon an operation, which was effectually performed,
by pressing  the  rectum with the forefinger introduced against the
sacrum, and then by means of a concealed bistoury passed through
the perforation already made with the probe, &c., dilating the par- 
PUNCTURE OF THE UTERUS.
461
tition freely in a lateral direction, first to the  left and then to the
right side.   A large quantity of grumous blood  gushed out, probably
menstrual,—which  had been retained in the upper part of the vagina,
which latter organ had been thereby distended  into a large  oval
sac, having, however,  a heahhy os uteri at its upper part.   First
a plug of lint, oiled, was used to keep the passage dilated, but being
difficult to be maintained in ph\ce, a wooden plug was substituted
and kept up by a bandage.  TNis last, which was, as we  think, in-
judicious  practice,  caused much irritation  and  was, very prudently,
soon replaced by a gum-elastic reotum bougie.
  Dr. Mott, who has performed a considerable number of these ope-
rations, both where there  was totrxl or only partial  occlusion, and
with unvarying success, and with most  satisfactory results to  such
particularly as had had effectual sexual intercourse and utero-gesta-
tion completely suspended by this occlusion for years, gives a decided
preference to a plug of proper length, rotundity and shape, composed
of  a portion of sponge nicely adjusted within  a  cylindrical sac of
suitable  size,  made of thick goldbeater's skin, or thin caoutchouc
cloth tissue, kept constantly oiled when applied, and  to be renewed
by  washing the bag and inserting a fresh, clean, and dry portion of
sponge as often as it  becomes infiltrated with the utero-vaginal dis-
charges.
  The passage should be also, occasionally, say once a day or oftener,
cleansed out with an injection of tepid weak soap and water, until
cicatrization is completed.
  Imperforate  Vagina.— Dr. W.  Shuttice of Mathews,  Virginia,
(Amer. Journ. of the Med. Sc, new series, vol. VII., Phil., 1844, p.
243, 244,) in a  case  of imperforate hymen in a  young lady  aged
eighteen, who had never menstruated, and who, in consequence, had
her abdomen so distended as to give rise to the suspicion of a tumor
or of pregnancy, successfully relieved his patient by puncturing the
tense partition, which  gave the patient immediate relief, and as sud-
denly reduced the swelling  by the loss of no less than six pounds of
dark, tarry, grumous, uncoagulated, retained catamenial blood.  The
discharge continued for several days, and  the surgeon supposed the
patient lost altogether, at the operation  and in  this interval,  some
eight pounds of menstrual blood.   The cure was, of course, accom-
plished in  this manner at once.  All such cases show the  necessity
of surgeons themselves making a close examination per vaginam, as
false delicacy of young ladies or their  relatives often piccrastinate
relief until it is too late. T.]

            Article  III.—Puncture of  the Uterus.

          § I.—The Occlusion of the Neck of the  Uterus.

  The neck of the uterus, like the vagina, may never have had an
external opening, or it may have been closed up by accident.   This
however is quite a rare occurrence, and one which many practitioners
have supposed they had met with, where in fact  it did not exist.  It is
evident, for example, that the neck of the womb was  not obliterated
in the case quoted by M.  F. Hatin, (Journ. des Conn. Med.- Chir.
t 
462
NEW ELEMENTS  OF OPERATIVE SURGERY.
 1839, p. 111.)   The  error, moreover, would be so natural  in such
 cases that M. Galopin, (Gaz. Med.,  1838, p. 714,) who, under the
 supposition that there was an obliteration of  the neck of the uterus,
 performed the vaginal Coesarean operation successfully, both for the
 mother and infant, and who adds that his confrere, M. Lannelongue,
 witnessed the fact, might also have readily committed a mistake of
 this kind.  Nor is it scarcely probable that the occlusion was  com-
 plete in the patient operated upon by M.  Stoll, (Ibid., 1839, p.  185.)
 M. Pacoud, (communicated by the author, April, 1839,)  who, out of
 more than 100,000  accouchements, of which  we have an enumera-
 tion in his school, had not yet met with one instance of  this  disease,
 nevertheless appears to have finally encountered a very decided case
 of occlusion.  The first thing to be done after we  have ascertained
 the imperforation of the uterus and its distension by any liquid, is to
 endeavor to find by means of the finger, some trace of  the neck in
 the place where it ought to exist, and should it be found to  endeavor to
 introduce into it an ordinary sound, in order to remove  the  impedi-
 ment.   Otherwise we must proceed to its  perforation, which has now
 been performed a great number of times, with  various sorts of instru-
 ments.   Some recommend that we should first make a puncture by
 means of the trochar; others that we should  prefer the straight bis-
 toury wrapped in a small band to within  some lines from its point.
 Even the pharyngotome has  had  its  partisans.   Dance  relates that
 Barre used a long  canula, including  a spear-shaped stilette, which
 latter had a groove upon  its concavity. In this matter each may fol-
 low  his own pleasure and select the instrument which is most agree-
 able to him.  It is evident, moreover, that a bistoury of some length,
 concave and wrapped in linen, and guided upon the left forefinger,
 would fulfil all the indications,  and  that the sound with its spear
 stilette, (sonde a dard,) or any trochar whatever, or the  pharyngo-
 tome, would equally attain the object  in view.  However this  may
 be, the  trochar and the bistoury are  in my opinion the two instru-
 ments which ought to be preferred.  All that is necessary is to make
 an opening sufficiently large for the liquid to escape, and  not to ven-
 ture too far towards the bladder or rectum.   As in the  case of the
 vagina, we must also be on our guard against a return of the difficulty,
 and  do all in our power to prevent the opening we  have  made from
 closing up again, unless the natural neck of the uterus has ultimately
 become re-established.  We should therefore  endeavor to introduce
 into  the uterus the end of a gum-elastic sound, in order to keep the
 wound  open.  In the operation which M. Hervez  de Chegoin per-
 formed  with success,  he  had  recourse to a  trochar whose  canula
 served for the introduction of a bougie, which in its turn was  used
 as the  conductor  for the  end  of a sound destined  to remain in the
 wound, and which was subsequently replaced  by a female catheter.
 This is the  most prudent  course of  treatment we can  adopt, and
which  almost all  practitioners have deemed it advisable to  pursue,
whether they have  used  the trochar,  bistoury or  any other instru-
ment.  Having spoken  in detail in  another work (Traite d'Ac-
couch., t. II.,  p. 216)  of the  obliteration of the neck of the uterus
during pregnancy and of the remedies it requires, there is no neces-
sity of my dwelling upon it any longer in this  place. 
PUNCTURE OF THE UTERUS.
463
                        § II.—Retroversion.

    Puncture may also be required for another disease ; I mean retro-
  version of the uterus during pregnancy.  When the reversion back-
  wards has continued beyond the third or fourth month, it is some-
  times found impossible to  effect the reduction.  The cause of this dif-
  ficulty lies in the constantly increasing volume  of the uterus.  The
  remedy in a desperate case, which would naturally present itself to
  the mind therefore, would be the extraction  of its contents.  But as
  the delivery of the infant should not be undertaken, we have no other
  resource than to extract the liquid contained in the membranes of the
  foetus.  Puncture of the uterus, which had already been recommen-
  ded by Hunter in cases of retroversion, has been frequently perform-
  ed with success.  M. Jaurel, of Rouen, has published a case, and an-
  other occurred at Lyon, under the notice of MM. Voucel  and Bou-
  chet, while M. Baynham  has furnished a third.  The woman being
  placed as in the preceding case, and supported by assistants, the sur-
  geon endeavors to find in  what  direction towards the rectum or vagi-
  na the uterus is most strongly inclined.   A  rule which is  not to be
  infringed upon, is to begin by doing all in our power to reach into the
  uterus through the opening in the neck.  When we find this impossi-
• ble, puncture through the vagina will be attended with less danger than
  through the rectum, inasmuch as it does not unavoidably lead to a
  perforation of the peritoneum, and  does not expose us  to the same
  danger of wounding the placenta.  It was however, through this last-
  mentioned  organ that  M. Baynham  effected  his puncture, because
  probably the development of the womb was much more  considera-
  t)le in that direction than towards the vagina.  We must admit, how-
  ever, that in general the employment of the  trochar leaves behind it
  no fistulous opening  either in  the  intestine or uterus, and that the
  wound closes up almost as soon as it is withdrawn.   In the case of
* M. Baynham, only about two  ounces  of fluid escaped  through the
  canula, which however was found sufficient to enable him to  effect
  the reduction.  Abortion  took place at the expiration of a few days,
  and the foetal envelopes, which were found entire, still contained sev-
  eral ounces of water:  the placenta had been perforated, as well as
  the abdomen of the child. In  such cases, the trochar should have
  more length than that used in  ordinary paracentesis, and  should be
  somewhat curved.   That of Fleurant, for puncture of the bladder
  through the anus, would answer  very well.   As it  may become
  caught in the placenta,  and as the foetus or  cord might  close up its
  opening, it is well to plunge it in to a sufficient depth, and to have a
  stilette of such length that it may go beyond the canula, to clear out
  its upper opening, and  thus enable the liquids to escape.  After a
  puncture of this kind, we  should hasten to  replace the uterus  in its
  natural position.  The treatment afterwards  required,  would very
  naturally comprise  nothing  more than  the  precautions necessary
  during pregnancy, were it not  that abortion is almost inevitably the
  result of this operation. 
464
NEW ELEMENTS  OF OPERATIVE SURGERY.
            Article IV.—Reversion of  the Vagina.

                §  I.—Excision of the Integuments.

  M. Dieffenbach (Gaz. Med., 1834, t. II., p. 20,) has suggested that in
place of reducing the reversed vagina, and  restricting ourselves  to
keeping it in its place by means of pessaries, we might apply to this
prolapsus with advantage, the method long since adopted by Dupuy-
tren, for that of the rectum.   He  commences therefore, by effecting
the reduction of the organ ; then,  in order to prevent the return of
the prolapsus, he excises entirely around its  vulvar  opening  the re-
laxed folds of the inner surface of the labia majora, or perineum.
This is done without any difficulty, by means of the forceps, and a
good pair of scissors. The folds removed, should leave the same num-
ber of radiations whose  centre of convergence is in the vagina, and
be arranged in such manner that their extremities  penetrate from
half an inch to an inch into the interior of this  passage.   The dressing
consists of nothing more than cleansing daily these  small wounds, or
if, in order to obtain an inodular cicatrix, we encourage their suppu-
ration, we introduce a meche of considerable size, the base of which
might readily furnish a small pledget to each  of these incisions.   The
object in view by this operation, is to contract the vulva and the en-  ,
trance of the vagina, by imparting to these organs a degree of solidity
and resistance which they had been for a long time deprived of.

            § II.—Excision of a Flap of the Vagina.

  Though followed by a successful issue, the  process of MM. M. Hall
and Herning, (London Aled. Gaz.  and Gaz. Med. de  Paris, 1832, p.
32,) and which consists in excising a  large elliptical  flap from the
mucous  membrane, and in the  immediate reunion of the  wound by
suture, would  evidently  be  much less adapted  than the preceding  •
operation,  to the reversion of the vagina.   I  shall return however to
this process when speaking of prolapsus of  the  uterus and diseases
of the rectum.
  Should the prolapsus be ancient and the  tumor have undergone
such degenerescence or transformation, as  to render  its  reduction
utterly impossible,  as appears to have been the  case  in the instance
published  by M. Berard the younger, and should  the patient have
absolutely made up her mind to be relieved  of it, there is  evidently
no other resource to offer her than extirpation.   Unfortunately, it is
difficult in such cases to ascertain with  certainty if the vagina alone
has prolapsed, and that  the uterus is not included in the diseased
mass, so that the operation would necessarily be attended  with seri-
ous dangers.  It would  be performed, moreover, in  the same  man-
ner as we shall describe in speaking of ablation  of the uterus, whe-
ther we should  have deemed  it advisable to use the cutting instru-
ment or have given the preference to the ligature.

       Article  V.—Prolapsus  (descente)  of  the  Uterus.

  Since the first publication of the preceding portion of the text, the
method  of  contracting the vagina as a  remedy for prolapsus of the 
PROLAPSUS of the  uterus.
465
uterus,  has  been  introduced  into  practice  under various  forms.
Some have proposed  for this purpose cauterization, or scarification
of the tissues,  while  others have recommended to slough off flap9
from the vagina by means  of the suture.  There are those again, in
fine, who restrict themselves to the contraction of the vulva.

                       § I.—Cauterization.

   It is in France that the general method originated under two prin-
cipal points  of view.   In  1823, M. A. Gerardin transmitted to the
Medical Society of Metz, a memoir, which he also addressed in 1824
to the  Royal  Academy of Medicine, and  upon  which M. Beaude-
loque (Arch. Gen. de Mid., t. VIII., p. 132) was appointed to make
a report.  In this treatise,  which I have read in  manuscript, the au-
thor proposes as a remedy for prolapsus of the womb, that we should
contract or obliterate the vagina by cauterizing its interior.   Since
that time this recommendation has been adopted in various hospitals.
In 1833, M. Laugier  attempted to cure one  or  two women in  this
manner, by making use of the nitrate Ecid of mercury.   Being  my-
self also desirous of ascertaining what virtue  it  might possess, I
treated, by means  of cauterization with the red hot iron in 1835, at
the hospital of La Charite, a woman who had  been for a long time
afflicted with a prolapsus of the uterus, and I have understood  that
an attempt  with  cauterization  had  also been made  use of for the
same purpose, but without success, at  the Hospital of St. Louis. It
has  been considered that to obtain success, it would be necessary to
caulerize either by means of chemical substances, or the red hot iron,
several lines upon the vaginal cavity to such degree as to cause them
to mortify  to  a  sufficient  depth, and to  become  transformed  into
an eschar, from the neighborhood of the neck of  the uterus as far as to
the vulva.  Considered in  itself, the operation is exceedingly  simple ;
having inserted into  the organs a jointed speculum, or that of Dug6s
or M. Ricque, or any other, we apply  a pencil charged with  caustic
matter, or the  reed-shaped cautery, either upon  the two sides or the
posterior median line, or upon some other intermediate spaces of the
vagina, in such manner as  to destroy their vitality.
   It is important not  to forget, while we are proceeding in this man-
ner, that the bladder  and urethra are in front, the rectum behind, and
the  cul  de sac of the neighboring peritoneal  cavity very near the
posterior lip of the neck of the uterus.  During the time the  eschars
are  being exfoliated, we  confine ourselves to  emollient injections,
general  baths and antiphlogistic treatment.  At  a subsequent period
we promote the cleansing and cicatrization of the wounds, by deter-
gent, and afterwards  resolvent injections, and place the patient on a
more substantial diet.   Having now established in this region wounds
with loss of substance, the surgeon  has  reason  to expect that  after
their cicatrization the vagina will necessarily be contracted by them,
and  that being intermingled with inodular seams, they will be capa-
ble of presenting an  obstacle to the descent of the uterus.  Doubt-
less, we cannot assert that success would  never crown  an  attempt
of this kind.  The  bridles, septa, and coarctations  of every  descrip-
tion,  which  are sometimes accidentally formed in the vagina, and
   vol. m.                    59 
466
NEW ELEMENTS OF OPERATIVE  SURGERY.
 which I have spoken  of above, are  a sufficient evidence  that  the
 uterus is, under such circumstances, compelled  in some cases to re-
 main above the vulva.   A  neck which did not allow  of the  in-
 troduction of the little finger, and which was found in  the vagina, at
 the depth  of two inches and a half in a lady whom I saw  with  M.
 Berigny de Meulan, perfectly fulfilled in that part the function of the
 best constructed pessary.  A semilunar septum, situated an inch higher
 up, performed the same office in a lady whom I saw with M. Andral,
 the father.  I have  already spoken of a patient of M. Gerardin, who
 after having had a pessary for several years successively, imprisoned
 in these parts, found herself after the  extraction of this body, cured
 of her prolapsus by means of a circular  contraction  formed on  the
 middle portion of the vagina.  It is, nevertheless, true that these  co-
 arctations are not effected without difficulty, that the women treated
 in this manner by M. Laugier, have had their prolapsus return, and
 that the disease was also reproduced  in the woman operated  upon
 by me at the Hospital  of La Charite, though I  had cauterized to a
 considerable depth four radiating  lines on the vagina.  The pliancy
 and  distensibility of the tissues,  and  the  quantity of fluids which
 readily accumulate  in these parts, all present an obstacle to our pro-
 curing in  this region, at pleasure, a  solid and durable contraction.
 As it is an operation, moreover, which would not be unattended with
 danger,  it  does  not consequently, in my opinion, deserve to be  re-
 tained in practice.

                        § II.—Excision.

  Contraction effected by means  of excision, first  attempted by M.
 Ueming, (Gaz. Alid., 1832, p. 32,) and afterwards by M. Ireland, in
 1834, and by M. A. Berard  and  myself, in 1835, already enhances
several modifications.   M. Berard has followed in every respect the
process  of M. Ireland ;  that is to say, that after having  excised from
each side of the vagina a strip near an inch wide, and from two to
three inches long, he has reunited the wound by means of the suture.
The patients, who at first appeared to have been effectually cured.
have, nevertheless, had  their infirmity return upon them  shortly after!
Inasmuch as the walls of the vagina are under such circumstances
very much thickened, or as it were hypertrophied, and  that  there  is
 almost always existing at the same time a reversion  of the  bladder
or rectum, that is, a  cystocele or rectocele, I have  deemed it better to
make the incision of the tissues in front and behind rather than on the
sides.  Desirous, moreover, of rendering both the incision and suture
more easy, I have commenced by placing the threads through the
base of  the fold which is to be removed.  Afterwards detaching the
entire organic strip, I have found it exceedingly easy  to unite the
borders  of the wound, by knotting each of the threads, and thus com-
pleting the suture.   For this purpose I  place the woman on her back ;
I then secure by means of an  erigne, and as high up as possible, the
median posterior crest of the  vagina, while  an assistant, in the same
manner, raises up  its perineal extremity.  Immediately consigning
the two  erignes to the assistant, I introduce the forefinger of  the left
hand into the rectum, in order to protect the movement of the curved 
PROLAPSUS OF THE UTERUS.
467
needle, which latter, conducted by the right hand, is to pass three or
four double threads through the base of the vaginal fold, taking care
to commence with the one which is to be highest  up, and to termi-
nate  with that  which is nearest to the vulva.   Another assistant
holds all these threads stretched out, while the surgeon provided with
a good bistoury, divides the  tissues  on one side, and  then on the
other, and finally from  above downwards, at the distance of three
lines  inside of each point of suture.   The same manipulation is to
be  made use of upon the anterior median line, after which nothing
is easier than to reunite  the wound by knotting each of the threads
on  one of its sides.  Having cut  near the  knot one of the  halves
of  each ligature, the  surgeon gathers the remainder together, and
brings  them into the  fold of the groin, where he  fastens  them un-
der a piece of  adhesive plaster.   The ligatures  rarely come  away
until  after the expiration  of  from  six to ten days.   Sometimes, in
fact, they do not cut  through the  tissues, but seem to  be relaxed,
and would  soon act in  the same manner  as a seton, if we did not
take  the  precaution to cut them.   A  patient whom I operated upon
in  this manner,  in 1835,  and who appeared  to be cured during
nearly three months that she remained in  the wards of the hospital,
had when she resumed her labors, a few weeks after, a  return of
her prolapsus.   I operated upon another woman, in 1838, with a com-
plication of rectocele, and who  died  three months  subsequently of
an  ulcerous enteritis, the prolapsus  in her case also having begun to
reappear.  But  it is  proper to add, that in this last case the projec-
tion from the vagina was  prolonged into  the pelvis, by means of a
plain,  soft cylinder of a vascular  and fleshy appearance, three to
four inches long, and of the  size of a child's fist, and which  termi-
nated on a line with the fundus  of the uterus, by a kind of globular dila-
tation  of a  venous, or as it were  fibro-muscular texture, possessing
some  analogy to that of the uterus.  Do these facts suffice to prove
that the process of excision does not yet constitute the efficaceous
remedy for prolapsus of  the uterus  or vagina ?  In answering in the
affirmative, I have too much fear that future experience will not re-
verse my verdict.

                         § III.—Suture.

  A distinguished  surgeon of Italy, M. Bellini, (De la Colpodesmo-
graphie, <£e., 1835,) has proposed to mortify one  or two flaps of the
vagina by means of a suture which  should  represent the form of an
inverted [±, and which he prolongs  as far back as to the neck of the
uterus; but it is  at once evident that this process is at the same time
more tedious and difficult, and less certain  than the preceding ones.
In conclusion, I do not believe that these different modes of operating
upon the vagina will attain the object proposed, or that it will be long'
before they fall into disuse.

                § IV.—Contraction of the Vulva.

  The idea of contracting the  vulva for prolapsus of the vagina, and
which originated from the practice  of Dupuytren for reversions of
the  rectum as applied to prolapsus of the womb, appears to present 
468
NEW ELEMENTS  OF OPERATIVE SURGERY.
 some few advantages over the preceding mode.   Certain it is that,
 made  trial  of by different  surgeons,  it has  always procured, if
 we  receive in the  literal  acceptation what they say  of  it,  very
 encouraging results.  M. Fricke, who performs it by a new  process,
 wrote  to me in 1835, that at that period he  had already used  it in
 twelve instances, and always with success.  This surgeon proceeds
 nearly in the same manner as for suture of the perineum; that  is to
 say, that he abrades the two posterior thirds of the vulva by  excision
 of the  tissues, and  then reunites  the sides of  the wound  by  three or
 four points of simple  suture.  The perineum is in this manner found
 to be prolonged an inch or two in front, in such manner as  to close
 up all  egress to the  neck of the womb.   Taking  care to leave an
 aperture behind and  to preserve a portion of the vulva in front, M.
 Fricke (Ann. de Chir. de Hambourg, 1833; Gaz. Med.,1835, pp.
 249, 268) in  this manner guards  against accumulation of liquids in
 the vagina, and is enabled  subsequently to re-establish the sexual
 functions.   M. Knorre (Gaz. Med., 1839, p. 185)  states that he has
 succeeded with this operation  in one instance.   The same  was the
 case with M. Loscher, (Ibid.,) but though  it did not fail in the hands
 of M. Fricke at Hamburg, I am compelled to state  that a patient
 operated upon by him in my department at La Charite, in 1837, was
not cured; that M. Plath, (Ibid., 1837, p. 13.) in making trial  of it
upon another woman  was not more fortunate, and that one of the two
patients also upon whom I made use of it did not derive any benefit
from it.  It  is nevertheless certain  that  this process, denominated
Episioraphy by M. Fricke, ought to succeed more frequently  than
those which have been  mentioned  above.  The  ruptures of the
fourchette and perineum, and the  enlargement of the vulva from any
circumstance whatever, are, it  cannot be denied, the most common
predisposing causes of prolapsus of the uterus.  It is readily  con-
ceived, therefore, that an  operation which replaces the parts in their
original condition, and which even has the effect to diminish  the nor-
mal dimensions of the  vulva, must hold up the uterus in such manner as
to efface the two lowest portions of its prolapsus.  As to the operative
process, it is  moreover precisely the same as that which will  be men-
tioned  under the head of suture of the perineum.  The same weight
which  is felt from  the womb at the fundament, after an operation of
this kind, is also found  in women who wear a pessary.  This  dif-
ficulty  moreover could be remedied in this as in any other case, by
means  of a hypogastric girdle, provided with its infra-crural band-
 age and its accompanying perineal cushion.
  [A complete prolapsus  both  of the uterus  and vagina, has been
stated in one recent instance at least, to have not prevented the  safe
 delivery even of twins !   M.  Rathman, (Med. Zeitung von Preussen
 1842, No.  33—Arch.  Gen. de  Med.  de Paris,  le ser., t. II., p.  23l'
 &c.,j relates a case of this kind in a woman who had had incomplete
 prolapsus of the parts in question from the age  of sixteen, and who
 when she was arrived at the age of twenty-two, was on' Februarv
 17, 1842, delivered by him of two well formed twins at the full term
 but dead,  by means  of the  forceps ; not, however, without much
 difficulty and laceration of the parts.  The  woman,  however, re-
 covered.  T.] 
REDUCTION OF THE WOMB AND  VAGINA.
469
       Article VI.—Reduction of  the Womb and  Vagina.

                               §1.

   Whether it be the vagina or uterus which presents itself at the vulva;
 whether the uterus descends to that part and exhibits there its neck, or
 alter having been everted upon itself, shows itself there in the form of
 the finger of a glove ; whether the third half or whole of it has pro-
 truded ; or whether, on the contrary, it has only been retroverted in
 the interior of the pelvis, certain it is, that the reduction and replace-
 ment to be effected exact the observance of certain rules, whose im-
 portance is not to be overlooked  by the surgeon.  These  displace-
 ments are sometimes accompanied with symptoms which require at
 first some attention on the part of  the practitioner.  There  are some
 of these which are  to be removed before  returning the organ,  and
 others which  cannot in  reality disappear until afterwards.   Inflam-
 mation, fever, and symptoms of general reaction, are evidently those
 which belong  to the first class ; while leucorrheal discharges, exco-
 riations, 'and ulcerations, belong to  the second.  The engorgement
 and painful state of the tumor even, should not arrest us, unless they
 present an actual mechanical obstacle to the return of the parts.   In
 fine, the best remedy, the best calmant, and the  surest antiphlogistic
 means also, is to  be  found in the reduction, whenever it can be ef-
 fected.  If it  is the vagina,  after having wrapped the entire surface
 of its border in linen  besmeared  with  cerate,  we make gentle
 pressure  upon it with the  fingers  from the circumference to  the
 centre, before pushing it from below upwards.   The  uterus everted
 upon itself would require the application of  the same linen;  but  it
 might be  advantageous to direct  the ends of the fingers  upon  the
 most projecting point of the tumor, in order to  make it return with
 more  certainty, and to push  it up  completely above the  superior
 strait.  When there is nothing more  than a fall or prolapsus of  this
 organ, we also envelope it in linen, and in the same way as for  the
 vagina endeavor  to contract its base a little, at the same time that we
 push back its apex, in the direction of the axes of the pelvis.

                              § II.

   If the case is one of retroversion, it sometimes becomes necessary
 to vary the position of the patient,  who in the preceding cases may
 remain in  a horizontal position, at the same  time that her limbs and
 all her muscles are kept in a state of  relaxation.   The first  thing to
 be done to straighten the uterus,  when  it  has become retroverted
 in the pelvis,  is  to  secure,  by means  of the  fore and middle  fin-
ger of one of the hands, the  periphery of the os tincae (le museau
de tanche,) which usually is  found  to have become lodged behind or
 above the pubes.  If this does not answer, we  introduce  some of
 the fingers of the  other hand into  the  rectum, in order to  push  the
 fundus of  the organ upwards and forwards, while on the other hand
 we endeavor to make its neck  descend.  But when these attempts do
 not succeed, it is  recommended to place the woman  upon her knees
 and elbows, in order that the abdominal viscera, by their weight, may 
470
NEW ELEMENTS  OF OPERATIVE SURGERY.
 assist in drawing the womb towards the umbilicus, at the same time
 that the surgeon is endeavoring to dislodge it.  If all these resources
 fail, we may, should it be practicable, imitate Dusaussoy, who, intro-
 ducing the entire hand into the intestine, was  enabled to overcome
 difficulties which no other means could remove but that.  Finally,
 if the finger could not get  a sufficient hold upon the neck, we should,
 after the  manner of M.  Bellanger, introduce into the bladder through
 the urethra,  the  flat catheter  of Segrot, or any other  of the same
 form, or as I have done in two instances with advantage, an ordinary
 male sound, which could be afterwards  used as a hook by turning its
 concavity backwards.  I have no  necessity of remarking, that for
 simple displacements of the uterus in the pelvis, and in all circumstan-
 ces  where it is practicable in other  cases, we should begin by empty-
 ing  the bladder by means of the catheter, nor that in certain cases
 we may very conveniently grasp the organs to be reduced by means
 of the fingers directly, without  the necessity of covering the parts with
linen.  Repose, the horizontal  position, the proper kinds of injections,
 one  bleeding, and the  antiphlogistic regimen in general, are applicable
 to the sequelae of this operation, as to those of most others, for the pur-
pose of calming the irritation which must  have been  produced, and
for enabling the tissues to resume their customary functions

                   Article  VII.—Pessaries.

   The name  of pessary, which was formerly understood to  mean
any  substance introduced into  the vagina to support  the uterus and
prevent its displacement, is no  longer applied at the present  day but
to certain  instruments of a determinate form.  Thus the bladder
which Columelle  introduced into the genital parts of cows where
he filled it with air, which bladder certain surgeons afterwards made
use of in the same manner in women ; together  with  the  masses of
linen and tow mentioned by Moschion and Absyrte, (Peyrilhe, Hist.
de la Med., p. 38,) are at  the present day designated by other names!

                  § I.—Pessary of the  Vagina.

  Among  the  pessaries which  are still used at the present day there
are some whose object is to keep reduced the hernias which have pro
traded through the walls of the  vagina, or to prevent the prolapsus
and eversion of this organ itself; while others are exclusively desiW
ed to prevent  the descent and deviations  of the uterus   The f?
class may  be  divided  into two orders.   Some consist of a  hollow
cylinder about four inches long and  of a  sufficient diameter to fill un
the whole  organ ; these are called bung pessaries (nf><t*nir>*„    I  l
dor.)  The others, contrived by M. j'LaJC^Z^Z £
ceding in  this respect, that they are somewhat  flattened, and also
concave in front, sightly  dilated at their extremities, and havingonlv
quite a small canal in their centre.   The name of elytroidal pelZrv
by which this professor has designated them, would be more apnlfoa'
ble as it is seen to the pessaries en bondon, since the former  merefv
signifies a  pessary m the form of a sheath ; but the name is a matt^
of  little importance so  long as we understand  their construction 
PESSARIES.
471
Both  are  introduced in the same manner.   The  woman is placed
upon  her back, while holding her  thighs and legs moderately flexed
and kept apart.  The pessary being besmeared with cerate, is intro-
duced at its smallest extremity, like a speculum, into the entrance of
the vagina, and then pushed into the cavity of this organ from below
upwards,  and  from before backwards.   The elytroidal pessary, from
having a greater breadth in one direction  than in the other, is to be
introduced flatwise to the great diameter of the vulva, in such a man-
ner that its posterior angle being the first lodged in the vaginal open-
ing, may serve to depress the rectum as well as the entire thickness
of the perineum with  a certain  degree of  force; the other angle of
the same extremity is then depressed little by little  as it glides under
the pubic arch, after which there is no longer any difficulty in making
the instrument penetrate into the vulvo-uterine passage.   As soon as
it has entered into this part, we  give it a movement of rotation, which
places its convexity towards the intestine, its concavity forwards, its
upper extremity under the neck of the womb, and its lower extrem-
ity, which is the largest, transversely  above the ossa ischia.  The
bung pessary, from its forming only a sort of tube, whose walls are
very  thin, may in general be introduced with greater facility; but as
it is straight, and makes but little resistance, the organs soon ohange
its form, so that its presence soon ceases to afford any benefit.

                 § II.—Pessaries of the  Uterus.

  A.  The pessaries of the second order have varied much more in their
form and composition, than those which I have just described.   The an-
cients constructed them of an oval elliptical plate, of wood or cork,
which they afterwards covered  with a layer of wax ; they had them
also of gold, silver, copper, lead, and even of tin, and of all  kinds of
forms.  Those which are called gimblet-shaped, are either perfectly
circular or slightly notched in front and behind, like a figure of 8, or
depressed at the same time upon the four extremities of their princi-
pal diameters, or they are merely elliptical and flattened, and perfo-
rated in the centre.  In England, they frequently employ pessaries of
a globe form, sometimes hollow, at other times solid  and perforated
or not in their middle portion, and this is the  usual practice  also
adopted in America.  Wax and cork  have been long since rejected
in practice, since they readily become changed in the organs, and do
not possess a sufficient degree of suppleness.  The same remark ap-
plies to the employment of ebony, ivory and silver, unprotected,  be-
cause of their hardness or weight,  Pomarest, (Bonet, Corps de Med.,
t. III. and t.  IV., p.  103,) however, states that he kept up a prolapsed
uterus for the space of ten years, by means of a ball of wax.  At the
present day they are made almost exclusively of gum elastic ; except
that this substance  is  occasionally protected  by linen, hair, felt, or
wool, silk tissue, &c.;  in order  to have them as solid and  light as
possible, Mdme. Rondet, who makes use of a steel ring, well temper-
ed, and wrapped in hair and caoutchouc itself, has  contrived others,
the entire circle of which is hollow and filled  with air.  M. Houin, a
manufacturer  of instruments, has prepared some which have the form
almost of a solid bung, and which are,made out of pure caoutchouc. 
 472          NEW ELEMENTS OF OPERATIVE  SURGERY.

 Those of M. Tanchou are flexible, and represent the periphery of a
 funnel which is very flaring,  to receive the neck, and with a very
 short conical beak, to hinder them from turning over.  M. Rognetta
 has proposed some which have still another form.
   B.  M. Hervez de  Chegoin (Mem. de VAcad. Roy. de Med., t. II.,
 p. 310) having  remarked that the uterus in its descent almost always
 is inclined outside of the axes  of the pelvis, has shown that the form
 of the pessary ought in s;»ne  respects to be different for every wo-
 man.   According to this idea, we  require sometimes a ball  dilated
 in front, behind, or on its side, sometimes a bilboquet, bung, gimblet,
 or cap,  whose  border depressed in one direction  and raised up in
 another, may be placed between  the neck of the  uterus  and the
 wall  of the vagina against which  it is reversed.   In this  manner
 we prevent the anteversion or retroversion, and also the anteflexion
 and retroflexion, as  well as at the same time  the descent of the
 uterus.
   C.  Ivory, which has been rendered flexible  by the processes  of
 M. D'Arcet and M. Charriere, that  is to say,  by means of hydro-
 chloric acid and tannin, being more  easy to work  with, is infinitely
 better calculated to fulfil these indications than any other substance.
 With  this  preparation the pessaries retain their elasticity and flexi-
 bility  ; they cause but little irritation  to the organs, less readily un-
dergo alteration than most of the others, and may be constructed  of
the shape  desired, and almost immediately.
   D.  Physick still continued to use pessaries of gold or silver.  His
are globular, like those of the time of Denman or dark, and are com-
posed of two capsules united  at their base.   Those moreover which
have a little more breadth transversely than from before backwards,
possess the advantage of being introduced with more facility, and of
occasioning less disturbance to the functions of the  rectum and blad-
der.  They  are introduced even with more facility than pessaries of
the vagina.   The important point is  to make them reach into this
passage by means of the precautions above  mentioned.  By means
of the finger introduced into their ring or upon some part of their
circumference, we are always enabled by that means to  give them
their proper position, that is to say, to impart  a vibratory  movement
to them, which  places them horizontally in the pelvis, with  one of
their  borders posteriorly and  the other in front, and with their ex-
tremities towards the ossa  ischia; in such manner in fact, that the
 extremity  of the os tincae may rest on the upper cavity of the open-
 ing, which traverses its whole substance.
   E.  Women who have had their perineum  lacerated, or in  whom
 the vulvar orifice of the vagina is very large,  scarcely derive any
 benefit  from pessaries  of  the gimblet  or globular  shape,  which
 in general they  cannot keep up; so that we are soon obliged to find
 others which are more  perfect, and  which may be substituted for
 them.
   F.  Those described by Bauhin, and which have received the name
 of bilboquet pessaries, are formed of an ivory or wooden rinf, sup-
 ported by three branches,  and terminated by  a  root some  Inches
 long,  which is  perforated  at its free extremity with three  or four
 holes.   The cup of this instrument, which is intended to receive the 
PESSARIES.
473
neck of the womb, has sufficient depth to enable the menstrual or
other discharges from the uterine cavity 1o escape with facility be-
tween  the three  roots of its support.   The  cords  that are passed
through the lower openings  of this  pivot,  enable  us  to fasten it in
front and  behind upon a girdle which the woman is to wear constant-
ly.   Desormeaux having remarked that notwithstanding the notches
which are found between the circle of the bilboquet and its tail, fluids
sometimes accumulate below the neck of the  womb, and acquire
there irritating properties, proposed  to transform the  stem of the in-
strument into an actual canal, and to give to the cup itself the form
of a shallow funnel;  but in  spite of these precautions, matters will
still  occasionally become lodged between the orifice of the  uterus
and the instrument, so that there is not in  fact any good reason  for
giving a preference of this new pessary over the ancient one.  If, as
some practitioners recommend,  and Desormeaux  among them, we
should confine ourselves to adjusting the beak of the bilboquet above
the os coccygis, and in the interior  of  the vagina, rather than to at-
tach it  by means  of cords to a  body bandage, there would be too
much danger of perforating the rectum to justify me in recommend-
ing it, even though it should include a cork-screw  spring in its pivot,
as recommended by M. Recamier.
   G. Some persons, with a view to remedy the continual vascilla-
tions and  disturbances to which the instrument  is  exposed while the
woman is walking, have constructed those which have at their lower
extremity  a plate, about four inches long, concave above, pierced
with a large opening behind opposite to the anus, and with two slits
in front, in such manner that the  cords attached to the four angles of
this plate, enable it to  embrace  with sufficient  accuracy the  whole
extent of  the perineum from before backwards, and  to keep the bil-
boquet almost immovable in  the position we  have judged proper to
give to it.
  H.  Saviard, dissatisfied with the pessaries which  had been used
up to his time, undertook to  keep up the uterus  by means of a small
apparatus which is composed of a curved spring, adjusted upon the
hypogastrium  by one of its extremities, while the other entered into
the vagina to make compression there upon a tampon arranged in a
proper manner.  The one recommended by M. Villerme is based up-
on the same principle   Its stem represents a large arc, the concavity
of which when it is fixed in  its situation is intended to embrace the
anterior half of the pelvis.   It is a kind of a hook, the tail of which
being fixed upon the hypogastrium  enables its head, inserted in the
vagina, to  support or suspend the entire uterus.  M. Deleau proposes
another  which, so to  speak,  occupies a middle place  between the
bilboquet and gimblet.  It is  composed of an elastic spring surround-
ed with caoutchouc and turned into  spirals, so that the apex or  first
ring  is fixed, while the last or  base remains free, in order that it
may be tightened  or enlarged as required. When we wish  to ad-
just it, we fix it upon the head of a species of bottle brush or  piston,
after having contracted its circle to the proper dimensions.   After-
wards left to itself in the vagina with its point upwards, it accommo-
dates itself by its elasticity to the dimensions of the organ and runs
no risk of being displaced.  Preuner (These de Halter, French trans.,
   vol. in.                      60 
474
NEW ELEMENTS OF OPERATIVE SURGERY.
t. II., p. 393) describes one which is almost in every respect similar
in its form, but  I am very apprehensive  that its advantages, in fact,
are much more  apparent than real.
  I.  Whatever  may be the pessary we employ, we must not neglect
the precaution  of withdrawing  it from time to time, in order to
cleanse it.   Unless this were done it might become encrusted with
calcareous matters and ulcerate the vagina, and ultimately give rise to
serious accidents, too many examples of which are on record.   Wo-
men moreover  soon  learn  to perform this little  manipulation them-
selves, and to renew the pessary  at the proper time, without  having
occasion of any person to assist  them.   On  its  first application it is
advantageous to keep the  patient for some days in bed; otherwise
she might be liable to a degree of weight upon the fundament  and to
various kinds of irritation,  which would be much less to be  appre-
hended when we have given an opportunity to the organs to become
accustomed to the presence of the foreign body and to adapt them-
selves in some respect to it.
  J. Appreciation.—A question immediately presents itself.   Are
pessaries in reality of any advantage ?   There can be no doubt that
they may occasion much inconvenience  and quite a number of acci-
dents, and that many women even  are wholly unable  to support
them.  The pressure which they make upon the  rectum and bladder
is itself an obstacle to the functions of those two  viscera.  The neck
of the uterus itself, irritated by the contact of a body of this descrip-
tion, becomes lodged and strangulated in the opening of the pessary,
which latter in  its turn ultimately excoriates and  perforates the walls
of the vagina, if it does not also the coats of the intestine or bladder.
Many examples of this  kind  of  strangulation have been published,
(Bibl. Mid.,t.  XVII., p.  259; Journ.  Gen. de  Mid., 1826; Gaz.
Aled., 1834, p. 536.)  If we make use of the bilboquet, in whatever
manner we apply it, it inclines more in one direction than in another,
and ultimately after a certain length  of time depresses  the vagina
rather than the  os tincae, or at the  same time with it.   The gimblet
itself almost always turns over either in front or behind, and also fur-
nishes but a very poor support to the neck of the uterus.  As to the
bung pessary, the opening  at  its two extremities, which is thin and
almost of  a cutting edge, also very readily wounds the parts.   The
elytroidal  pessary, adapting itself to the vagina  and filling  up this
passage with a  certain degree of  accuracy, is less liable to  be dis-
placed, keeps up the  parts more  perfectly, requires less assistance to
be maintained in its  place, and from these considerations possesses
much fewer inconveniences than any of the others.  But as it forms
a  more considerable bulk and  occupies the totality  of  the  organ
many women find themselves on  this account  very  much  incom-
moded by it and it is difficult to keep it in place.  Since these instru-
ments  then are so far  from  being  innocuous, why should they be
continued in practice ?  It is at least certain that they should be pro-
scribed in a number of cases  in which they are had recourse to   In
a case of simple reversion, for example, or in that of the reduction
of a prolapsus  or  retroversion, pledgets and bags made astringent
by being saturated with red wine in which  roses  have been boiled
or by oxycrat or decoction of bark or diluted solution of sulphate of 
            FOREIGN BODIES IN THE GENITAL ORGANS.          475

alum, if introduced  and daily renewed in the interior of the vagina
during a certain length of time, would answer better than the employ-
ment of a pessary.  The pessary could also be very advantageously
replaced by fine sponges or linen properly prepared and held up in
the manner women make use of these during the time of their cata-
menia, should it absolutely become necessary to resort to mechanical
means to keep up the womb.   Again,  if the fall  of the organ  was
evidently favored by the too great dimensions of the vulva, excision
of the surrounding cutaneous or mucous folds, or episioraphy, though
more painful, ought  still in my opinion  to be preferred ; so much the
more so inasmuch  as  it would probably effect a radical  cure  and
allow of the continued  performance of conjugal duties.
   K. A  good hypogastric girdle, simple  when there  is nothing
more than an  anteversion  or  anteflexion, and combined with a pe-
rineal cushion in cases  of prolapsus of the uterus, would be a better
remedy, moreover, than most pessaries are for these different kinds
of displacements.

    Article  VIII.—Foreign Bodies in the  Genital Organs.

                      § I.—In the Vagina.

   The foreign bodies that we are called upon to extract from the
vagina are sometimes pessaries  or portions of pessaries which  have
been destroyed.   Some other substances, however,  have been found
there.   Dupuytren met there with a pomatum cup, the opening of
which was downwards.  In the two women mentioned by M. Grenier,
(These No. 7, Paris, 1834,)  it  was a case filled with needles, which
had been introduced closed, and become opened'in the vagina.  In the
cases cited by MM. A. Cooper  and Capuron they were portions of
sponge, which had been neglected and left there, and which had be-
come the nucleus of hard bodies.  Any person, moreover, may compre-
hend the varieties of form or substance which foreign  bodies  may
have that have got  introduced by chance, or by the volition of the
woman into this passage, as well as the kind of accidents which  they
may occasion.  There  have been found here pessaries that had  been
buried, as it were, for the space of 10, 15, 20 or 40 years, and which,
after having become encrusted with calcareous matters and under-
gone corrosion, or even become imbedded with fungous vegetations,
have produced pains, inflammations, and the most formidable array
of symptoms.  In a woman cured by M.  J. Cloquet,  so great an
alteration of the vagina was produced that it was taken for a cancer.
Ordinarily they ulcerate, and perforate either the bladder or rectum,
and even sometimes both those organs at once.  A woman desiring
to withdraw her  bilboquet  broke its stem, and finally forgot that she
left its ring in the vagina; at the expiration of a long period of years
she was  seized with symptoms which  obliged her to solicit the ex-
traction  of this  foreign body.   Dupuytren was  then  enabled  to
ascertain (Bull, de la Fac de Mid., t. VII., p. 136,) that  it made  a
projection at the same time  into the  rectum and the bladder.   M.
Berard  has published a still more remarkable  case, and to which I
myself was witness.  The woman, who was very advanced in  age, 
476
NEW ELEMEXTS OF  OPERATIVE SIRGERY.
 had quite forgotten her pessary since she had broken its stem twentv-
 nye years before.  It could be felt  naked in the bladder by means
 of the sound, and very distinctly in the rectum with the finger.  The
 vagina, which was almost  completely obliterated below, formed  no
 longer anything  more than a species" of cul  de sac having a small
 aperture in its upper part.   In the  case  communicated bv M. Lar-
 roche to M. J. Cloquet. (These de Concours,  1831, p. 100,) the  stem
 pessary had perforated  the rectum, where its  cup  had become the
 nucleus of a stercoral calculus, while its pivot occupied the centre of
 a urinary calculus in the interior of the bladder.  As the operation
 which is to be performed under such circumstances  must vary ac-
 cording to the cases which require it, it could scarcely be submitted
 to any special  rules.  If the pessary still  continued  to be free and
 nothing more was required than to subdue  the  irritation which  it
 produced, the forefinger introduced into its ring or on one  of its bor-
 ders, would  be quite frequently found sufficient to effect its extrac-
 tion.  If it were otherwise, a long  polypus forceps could be advan-
 tageously substituted for the fingers, or we might try to succeed bet-
 ter with a blunt hook guided and protected by the forefinger of the
left  hand.  When it projects into the rectum and  cannot be with-
 drawn through the vagina, we endeavor to grasp it  and bring it out
in the same manner through the anus.  In cases where its size is  an
obstacle to the  success of  the operation, it may be found useful  to
break it up into fragments.   If it is of ivory or wood, or any fragile
substance whatever, we may  do this quite  readily by means  of a
strong cutting  pliers or solid pair of forceps.  The  same cannot  be
said of metallic pessaries.   In such cases we have no other resource
than to make use of the file, which of itself would be of but very little
advantage, or of a small  saw introduced  into the rectum and  pro-
tected by a suitable canula, while we held the  foreign body by means
of a forceps in as complete a state of immobility as possible.   It was
with the saw that Dupuytren effected  his object  in the case which
 has  just been mentioned.   In a patient whom I saw at La Pitie, M.
 Lisfranc began by incising  the front part of the anus and a portion
 of the perineum,  in order  to obtain a wider entrance.  He  then
 grasped the pessary without  any  great  degree  of difficulty, and
 effected its extraction by a forceps held in the right  hand, while the
 fore and middle fingers of the left hand regulated the movements of
 the instrument at the bottom of the parts.   In  operating since on two
 similar cases, one at the hospital  of  La Charite. and the other a pa-
 tient of M. R. Gerardin, I did not find it necessary to incise the peri-
 neum.   The position of the woman  and the precautions necessary,
 before and after the operation, are the same as those for all the other
 processes which we have been describing  in  the preceding articles.
 If a tumbler or  vessel, either  earthen or  of wood, should produce
 accidents in the vagina, it would become  necessary after having  in
 vain endeavored to place them in the most suitable position and  to
 extract them entire, to break them  in their place  and to remove
 them by piecemeal.  Moreover, the intelligence of the surgeon will
 know how to supply the deficiencies to which books are necessarily
 reduced on this subject. The consequences of the operation are usu-
 ally very simple, unless the intestine or bladder has been perforated. 
POLYPI OF THE UTERUS.
477
It is remarked, that even in such cases fistulas soon become conside-
rably reduced, and frequently even finally close up entirely of them
selves.  Another peculiarity, no less remarkable, is this, that after the
pessary has been extracted, the descent of the uterus, in a consider-
able number of cases, does not again take place.  The vagina, which
has become indurated and contracted, and  occasionally transformed
into inodular tissue below the cul de sac, which had been long occu-
pied  by the foreign body, contracts  still  more when this latter  is
removed, and to so great a degree as to present an obstacle to the
womb and to retain it above.  The woman whom I operated  upon
in 1838 with M. Gerardin, presented  a fine example  of this modifi-
cation.

                      § II.—In the  Uterus.

   The  uterine  cavity sometimes  contains free  inorganic masses,
which Louis has described under the name of stones of the uterus.
These stones, which M.  Roux and Dupuytren supposed to be  pro-
duced by transformations of  fibrous  tumors, have been  frequently
noticed.  I have myself  seen  them both in the interior of  the organ
and in the midst of its tissues.  It is  certain  that in  a considerable
number of cases  the  masses in question are nothing more than
simple  earthy  concretions or  the detritus  of pregnancies.  One of
those which  I  had an opportunity of examining was of the size of a
large egg, round and bosselated, and enclosed in many parts of its
tissue, hairs  and some  particles  of osseous  as well as cutaneous
tissue, while its  entire  circumference  was  nothing more than  a
simple calcareous incrustation.  As they might give rise to accidents,
they have necessarily, on that account, attracted the attention of sur-
geons.  Hippocrates speaks of a midwife who extracted one of these
from the vagina of a domestic.  Aetius, who makes mention of them,
recommends that we  should endeavor to  make them pass into the
vagina by introducing two fingers into the rectum while  the other
hand is applied over the hypogastrium, so that we may push  them
from above downwards  in order to  grasp them with the tenaculum;
he also made use of dilatation and incision  of  the neck of the womb.
Louis thinks that we might introduce into the  os tincae a pair of scis-
sors with their cutting edges on the back, in order, by this  means,  to
divide and enlarge the  orifice of the womb  from within outwards,
and  thus favor the egress of the calculus.   In this method there  is
but one difficulty, and this is to ascertain whether  the symptoms
which the woman suffers under are attributable to the presence of
these foreign  bodies  or to other  affections.  As it  is frequently
impossible to ascertain this with certainty, nobody at the present day
would venture to make trial of the operation of Aetius any more than
that of Louis, unless however  the stone could be  recognized in the
neck of the uterus, to which part it had become approximated, or into
which it had more or less protruded.

             Article  IX.—Polypi of the  Uterus.

  There is  no method of treatment  recommended  for polypi  in
general, or those of the nasal fossae in  particular, which has not been 
478           NEW ELEMENTS OF OPERATIVE SURGERY.

applied to uterine polypi.   These last nevertheless have not, in this
respect, excited the genius and invention of surgeons to so great an
extent as the first.  Cauterization, which  seems to be alluded to by
Celsus, and which was  still eulogized  by Verduc, Volter, &c, and
also scarifications and the use of desiccants, as mentioned in the
work of Aetius and that of Moschion, have been long since aban-
doned.  On the other  hand the tearing of them out merely  or making
use of torsion with this, would be applicable only in a small  number
of cases.  If, moreover, the treatment of these diseases  should appear,
according to Sabatier and  many of the  moderns, to  have been so
much neglected  by the ancients, the reason  lies in  this, that until
quite  a recent epoch  they have  been designated  in  medical works
under the  name of affections which  are exceedingly different.   Phi-
lotenus, (Peyrilhe, Hist,  de la Med.,  p. 115, in Ito,) for example, evi-
dently confounded them with cancer, and Moschion with varices of
the uterus.   We can no longer entertain any doubt on this  subject,
when we see the mysterious Aspasia describing hemorrhoidal tu-
mors which  sometimes originate on the neck, sometimes at the fun-
dus of the womb,  but rarely on  the external  genital organs ; tumors
which are to be excised without  any hesitation when  they are hard
and white, which  are to be tied when they have a great tendency to
bleed, and among which some are found  which resist every remedy.

                        § I.—Varieties.

  In order to  comprehend  the  relative value of the  operative  pro-
cesses applied to uterine polvpi, and  to reconcile the different writers
who have treated of  them, it becomes indispensable  to say a word
respecting their origin and nature.  It can longer be disputed at the
present day that there may be developed in  the uterus tumors which
differ very materially from each other.
  A.  The small polypus mentioned by Z.  Lusitanus, and the excision
of which was accompanied with so copious a hemorrhage,  may be
compared  to the vascular or vivacious polypi which are so frequently
observed in the nasal fossae.
  B. M. H. Berard has noticed in the neck  of the uterus soft polypi,
which were almost entirely mucous, or to a great extent  similar to
those of the nose.  I  have seen in  three instances in the uterus ol
women, used in dissections at the Ecole Pratique,  tubercles of varia-
ble volume, containing small vessels, and which were continuous with
the tissue of the organ and yet without any pedicle.
  C. Dance, M.  Berard and M. Cruveilhier, as well as MM. Mayer
and  Meisner have, like myself,  met with those which appeared to
have  been the result of an actual partial  hypertrophy, either of the
body or neck of the uterus; that is to say, that they were continuous
wilhout any line of demarcation with the fibres of this viscus, from
the structure of  which, moreover, they differed in no respect what-
ever.  I published, in  1825, a case of this kind, the morbid specimen
of which I have  preserved in  alcohol.
   D. There are  others which are also continuous  with the tissue of
the uterus, but which are evidently a degenerescence or transforma-
tion of this organ. These last  are hard, elastic, and of  a  greyish 
POLYPI OF THE  UTERUS.
479
color.   When they are cut into, they present the appearance of a
lardaceous, semi-cartilaginous, homogeneous  white substance, desti-
tute of vessels, and in which it is impossible to recognize the slightest
appearance of fibres.  I have had occasion  to excise some of this
description, and in which  all  these  characters existed in  the  most
marked degree.
  E.  The most  common, by far,  are  nevertheless  those  which,
since the labors  of Bayle,  M.  Roux  and Dupuytren, are designated
under the name of fibrous bodies, and which are primitively developed
between the layers, and in  the tissue of  the uterus itself.   The three
cases of carcinoma  of the uterus  related by Pottier, (Bonet, Corps
de Med., t. III., p. 492, and t. IV., p. 492,) who, after having tied and
drawn, and  depressed the tumor to the vulva, effected its excision,
also the cases of fungus of the uterus extirpated by Ollulaire, (Ibid.,
t. IV., pp. 29, 31,) in two different women, and the enormous sarcoma
extracted from  the  vagina, by  Behrens, (Theses de  Haller, Sous-
 Vater, t. II., p. 179, 1718, French  trans.,) are evidently to be classed
with these fibrous bodies.  Certain facts induce me to believe that
these last mentioned  tumors quite frequently result  from an effusion
of  blood or  from a fibrinous concretion, which  has been scarcely
organized, but continued to retain its vitality, and to grow by imbibi-
tion in the  midst 6f  the  surrounding  parts.  Exhibiting always a
tissue  of fibres,  intercussated  in various  directions,  and grey or
whitish, as in  the  preceding species, these  also do not contain any
vessels, and are  covered over with a layer  from the uterus, which is
so much the more attenuated in  proportion as they are larger in di-
mensions, and which  may  be so much the more easily  recognized in
proportion as we approximate to their pedicle.
  F.  Fibrinous  Polypi.—A woman, 32 years of age, sought my ad-
vice, at the Hospital of Saint Antoine, in 1828.  For a month she had
occasionally observed a slight discharge. Upon introducing the finger,
I found a mass of the size of a small egg, somewhat swollen, of quite
a firm consistence, and which was prolonged by a distinct pedicle as
far  as to the upper part of  the neck.   I supposed  it  to be a polypus,
and the patient  was placed in a  bath, and  underwent  during the
space of three days, preparation for the operation.   Having intro-
duced my finger into the part, I again encountered the mass which
I had  at first recognized ;  but in endeavoring to1 reach its pedicle, I
caused it to fall into the vagina, and thus extracted  it.  It was a
fibrinous concretion, or simple clot  of  indurated  blood.  Thus we
have a new variety of polypus, in other words, fibrinous polypi.  A
sanguineous concretion, resulting from  the catamenia, or some  dis-
charge of blood, engrafts itself upon the neck of the uterus, and ulti-
mately becomes  organized  there.  I have  now seen four examples
of this kind at different degrees of organization.   Did  not  the poly-
pus in the form  of  a  cyst, with a long pedicle, as noticed  by M.
Arnott, (Encyclogr. des Sc Med., 1836, p. 315,) and which originated
on the anterior lip of the neck, belong to this  species ?
  G. Cancerous Polypi.—Schirrous or encephaloid tumors developed
in the tissues of the walls, or in the cavity of the womb, may descend
and dilate the neck, and present themselves in the vagina, under the
form of a polypus.  Three women were seen in this state at La 
480
NEW ELEMENTS OF OPERATIVE SURGERY.
 Charite, in 1836, 1837 and 1838.  I saw a fourth instance with MM.
 Roux, Marjolin and Sanson.   A surgeon exhibited  to the Academy
 of Medicine, under the  name of a polypus, a tumor which  he had
 extirpated in a  patient whom I subsequently saw with M. Magistel,
 and who in reality was affected with a cancer.  In the case of M.
 Arnott, (Encyclog.  des  Sc. Med.. 183G, p. 315,)  this description of
 cancer caused an inversion of the uterus.
   H. True polypi may in their turn be mistaken for tumors of an-
 other character.  In 1823 MM. Richerand and J. Cloquet removed
 one of the size of a child's head, which had hung  for a great num-
 ber of years to the vulva of a woman, and  which they supposed
 to  be the extirpated uterus itself.   This  body when laid open pre-
 sented a cavity in its centre, and almost all  the  other characters
 of a uterus to so great a degree, that it was considered of a nature
 to demonstrate beyond dispute, the practicability of an amputation
 of the  organ.  The patient  died, and the uterus was  found entire
 in its  natural position—notning more had been removed than an
 enormous polypus 1  A woman from the country, who came  to the
 hospital of Perfectionnement in 1824, in order to have reduced, what
she called a falling down of the uterus, had at the vulva a  conical
tumor with a small transverse cleft at its top, which she had kept up
for a long time by means  of a pessary, and which I readily  pushed
back into the vagina and supported with  a bilboquet.  This woman
having returned home, after the expiration of a few days was seized
with pains in the abdomen, which induced her to come back to the
wards of the hospital, where she died the next day but one of a peri-
tonitis.  The tumor which I had reduced was a polypus attached by
means of a pedicle of the size of a finger to the fundus of the  uterus,
 which latter had  been inverted !
  I. The point of insertion of uterine polypi varies greatly.  Those
on the fundus of the uterus, if  their  pedicle is somewhat large, rarely
descend into the vagina without giving to the neck of the womb the
appearance of a simple ring, which might readily lead to the  suppo-
sition of an inversion of the organ.   A woman who was sent  to me
by M. Villette de Compiegne, and who died before  being  operated
 upon, was in this condition.  I have seen  two polypi with lono- pedi-
 cles originating at the summit  of the neck, one from the anterior and
 the other from the posterior lip.  M. Arnott mentions a similar case.
 In the interior of the neck as well  as in the cavity of the womb, the
 pedicle is almost always  found external to  the  median line, and al-
 lows of the finger or probe being passed  along  its side or above it.
 In a young woman, however,  upon whom  I operated successfully, it
 adhered throughout its whole  circumference, though the dilated por-
 tion of the tumor was scarcely larger in size than a nut.
   J. Polypi of the uterus,  whatever  may be their  species,  vary
 scarcely less in their form than in their  point of insertion.  In the
 case of a lady the polypus was globular, half the  size  of a nut, and
 adherent in the manner of a projection against the fundus of  the or-
 gan.  I  have  seen  those that were fibrous, cancerous, fleshy,  and
 mucous, of much larger  size, and which retained this  form, or
 where one of the halves was  imbedded in the natural tissues, while
 the other projected in the shape of a bump upon  the interior of the 
POLYPI OF THE UTERUS.
481
 aterus, or of its neck.  It would neither be easy or prudent to attack
 those of this description.  Though isolated, they continue to be glob-
 ular, and are not elongated into the shape of a pear so long as they
 are entirely included in the uterine cavity ; it is only when they ar-
 rive in the vagina that they become pyriform.  In a lady whom I saw
 with M. Lacournere. the polypus, which  had its root in  the uterus,
 extended itself under the form of a cylinder or penis as far as two
 inches outside  of the  vulva.  An analogous  fact was noticed  by
 Gaches, (Soc Med. de Montpellier, t. 33, p.  31,) and the same  modi-
 fications have been seen in polypi  of the vagina, properly so called.
 Frequently there exists several polypi at the same time.  Cancerous,
 fibrous, and  mucous polypi, are those which  especially multiply in
 this manner.  In 1838 I operated upon a woman who thus had four
 granular pediculated polypi, of the size of an almond or raisin-seed
 in the cavity, and on the lips of the neck  of  the uterus. ~

                  § II.—Spontaneous separation.

   When fibrous polypi have protruded through the neck of the uterus
 they undergo a species of strangulation, which in some cases ulti-
 mately  brings about their separation.  Levret has related two  ex-
 amples  of this  kind, noticed by Mercadier and Louis.  Mauriceau,
 Ruysch, and Hoffman, and before them M.  Donatus  and Rhodion,
 had mentioned similar instances.  Vacoussin, Gooch, M. Hue, (The
 Lancet, 1828, vol. II., p. 311,) and M. Hervez de Chegoin, have also
 related  cases of this kind.  I have had occasion  myself to  see one
 which yielded suddenly to slight movements which I made use of in
 order to  bring it out at the vulva.  Finally, M. Griffith, (Ibid., 1829,
 vol. I., p. 24,) and M. Guillon state that they have obtained the same
 result by the use of spurred rye, (ergot.)

                             § III.

  It was this spontaneous  separation of certain polypi which must
 have suggested the first idea of the  method of arrachement, which
 had already  been employed by Dionis,  Juncker and Heister, and
 which Lapeyronie and Boudou have  not hesitated again seriously to
 recommend.  These authors at  the same time advise torsion of  the
 pedicle, in order either to tear out the polypus with more facility, or
 to protect  ourselves  with  greater  certainty  against  hemorrhage.
 Torsion,  combined with simple tractions, being calculated to  become
 dangerous by drawing upon the tissue of the  uterus, Hevin under-
took, at  the schools of surgery, in 1753, to sustain a thesis wherein
he showed, that by holding the root of the tumor by means of  a for-
ceps at its upper part, while at the same  time we turned it upon it-
self, this danger would no  longer exist.  M. Pecot, (Arch. Gen. de
Med., 3d ser., t. II., p. 382,) who recommends this for soft polypi
after parturition, alleges that he has derived decided advantages from
it.  M.  Sanson  (Bull, de  VAcad. Roy. de Med., t.  I., p.  877) also
used this method in one instance with success, in a woman who had
been delivered, and  in whom there was a fibrous polypus in the
womb as large  as the fist.   A  similar instance was met with by M.
  vol. in.                    61 
482
NEW ELEMENTS OF OPERATIVE SURGERY.
Breon, who showed me  the  tumor in 1835.  M. Magistel was as-
tonished to find in a woman whom he had just delivered, a mass in
the uterus  larger than the fist.   We found after death, which re-
sulted from peritonitis, that the case in question was one of an enor-
mous fibrous polypus.  Manv of these polypi, moreover, are  very
easilv extracted.  A lady of Mans, whom  I  had seen, went to con-
sult M.  Recamier, who .removed her polypus with his  finger nail.
In another case, the polypus, which was  of the size  of a large nut,
and situated in the interior of the neck, was  detached by means of
tractions and simple frictions with the speculum.  I have torn them out
in several instances, even from the cavity of the womb, by means of
my fino-er.  In a woman who had just been delivered for the fifth time,
M. Stoll (Gaz. Med., 1839, p. 186) found in the vagina a polypus ten
inches  lonf, and weighing a  pound, and which he  was enabled to
detach from the uterus by means of his nails.  In the mother of  a
young  physician, I was enabled by means of my finger to detach
and remove a polypus as large as the half of an egg, though it was
situated in the  cavity  of  the uterus  itself.   To effect the arrache-
ment, we grasp the body of the polypus with the forceps of Museux,
with the ordinary tenaculum, or with the fingers if it is  not very
large, or with a straight or curved forceps.   We then make  regular
tractions, either simple, or  combined, with slight  movements of rota-
tion, until we have  brought the  tumor outside.   It  is scarcely ex-
cept  at this stage that  it would be practicable to make use of the
precaution of Hevin,  but  there  would be no longer any object in
doing so, for if we did not at this moment wish to  have  recourse to
pure and simple excision, nothing would be more easy than to apply
a ligature on the most contracted part of the morbid mass, and then
to excise the latter immediately below it.   I have been enabled in
three instances to tear out  small mucous polypi, situated  in the neck
of the uterus, by means of the polypus tenacula, guided upon two
fingers of the right hand.

                             §  IV.

   M. Recamier, who considers that these bodies may be destroyed
not only by arrachement, but  also by breaking them up (broiement),
has published two cases in support of his assertion.   In one the poly-
pus, which was of the size of the great toe, was implanted into the
upper part of the neck, and projected into the vagina.  Havino- made
strong  pressure upon it with the forefinger  of  his right hand, this
physician succeeded in  dividing and reducing it into a pulp, and was
enabled to accomplish its extraction in less than two  minutes; in the
other, finding it impossible either to tie or extract the tumor,' it was
ruthlessly broken up by means of the  erigne forceps or finders, and
reduced into a  sort of  packthread, the filaments of which constantly
slipped between the prongs of the instrument.  I cannot understand
the advantages of a process of this kind, and have no remark to make
upon it.
                             § V.

   The ligature to  uterine polypi is a much more  ancient  process
than Levret has alleged.  It is evident that Aetius and Moschion were 
POLYPI OF THE UTERUS.
483
acquainted with it, and Philotenus before them.  It must be admitted,
however, that we are indebted to Levret  for having  introduced it
into practice in modern times, by demonstrating that it is applicable
not only to polypi  that protrude from the vulva, but also to those
which are placed at the highest point in the genital cavity.  Numer-
ous instruments have been contrived  for performing this operation.
All those used for tying polypi of the  nose are applicable to it.  The
two tubes united in the form of a forceps, and which in  the  begin-
ning were much extolled by Levret, also those that Theden had con-
structed upon the same model almost, together with the instrument
of Lecat and that of Herbiniaux are  now abandoned, nor do  I think
that the ligature-holding and knot-tightening forceps of M. J. Cloquet,
which scarcely differs from that of Theden, will continue to be any lon-
ger used. Nor has the double canula of the first named author been any
longer retained in practice.  The two separated  canulas of Desault
or the catheters of  Niessen have been substituted for these.   Every
thing  leads us to believe that the modifications proposed by Clarke,
Laugier, Loeffler and Cullerier, as well as a great number of others
mentioned in the treatise  of M. Meisner, will also be  rejected  from
practice.
   A. Operative Process.-—The instruments being prepared, the fol-
lowing is the manner in which we should proceed.
   I. The operator  having ascertained the position of the polypus
and the dimensions of its pedicle  as correctly as possible, adjusts the
ligature  whicn he  intends  to use, which  should  be of fine silver,
according to the notions of Levret, but which is now more generally
made of silk or linen thread, taking care only that it shall have  suffi-
cient strength.  If we  make use of the two  canulas of Levret, we
adjust the thread in such manner that it may form a noose on one end,
and  be fastened at the other upon the ring which is found external
to the shoulder of each canula.   One  or two fingers of the left hand,
introduced as high up as possible, will serve to guide the whole to
the pedicle of the polypus.   The surgeon then immediately takes one
of the canulas in each hand ; fixes at the same point the one on which
the ligature is fastened below ; then makes the other pass around the
circumference of the pedicle until  he has been enabled to cross them ;
then twists and turns them together on their axis ; detaches the liga-
ture from them ; withdraws  them ; and then  passes the two united
extremities of the ligature through another tube, which is called the
knot-tightener, and which enables him to strangulate the tissues with
all the  force required.
  II. The instruments of Desault differ from those of Levret  in this,
that  the  two ligature-holders are separated and  free,  like those of
David, and also in one of them when shut containing a sort of forceps
which  terminates in a beak or bird's eye.   Half the ligature  is first
passed into  the simple canula and fastened below on  its ring; the
other half is then embraced by the forceps, which is closed by with-
drawing it into its canula, and which  latter has on its lower part a
notch to  secure the second  end of the ligature.   The apparatus is
then introduced in the same manner as before at the part  which pre-
sents the least resistance.   Having reached the pedicle, the operator
with his left h   d holds  the simple canula immovable, grasps the for- 
484
NEW ELEMENTS OF OPERATIVE SURGERY.
ceps-holding canula with his right hand, makes  it pass  around the
entire circumference of the tumor, and brings it back on a line with
the other in such manner that  the ligature forms a complete circle
upon the pedicle which is to be strangulated.  The forceps  pushed
through its canula opens and lets the thread out, and may be removed
without displacing  it.   The extremities  of this ligature  united into
a single cord, are then inserted through the opening of another me-
tallic piece some inches long and cleft at  its external extremity, and
the head of which, which has an eye, is bent almost at a  right angle
upon the body of the instrument.   This knot-tightener enables Us to
regulate the constriction in such manner as may be desirable, and to
augment or diminish it according to the indication presented.  It is
then to  be  finally attached  by  means of a thread upon  one of the
sides of the vulva, after having  protected the instrument with lint or
linen.
  III. The  apparatus of AI. Niessen is composed of two long curv-
ed silver canulas, which may be flexed or  straightened at pleasure,
and which serve as  the ligature  holder.   When  they have arrived at
the polypus, they are both inserted  into a third canula, which latter
is divided into two tubes by a partition, and is only an inch or two
long.  This last, which seems to be nothing more than a portion of
the double tube of Levret, is conducted as high  up as possible, from
below upwards, first by means of the fingers, and then with the ex-
tremity of a hook sound. Its object is  to strangulate gradually the
pedicle of the tumor, by forcing the upper extremities of the two first
canulas to approximate  each other  without  losing their parallel di-
rection.
  IV. We can scarcely understand at first  sight, what advantage there
would be in giving the preference to these instruments over those
of the French practitioners.  The canulas of the German author be-
ing no other than those of  Levret slightly elongated and curved,
might possess some  advantage perhaps, when we have to penetrate
to a great depth ; but the double tube intended to approximate them,
appears to me infinitely less adapted to attain this object than the knot-
tightener contrived  by Desault.   If, moreover, we wished to modify
this  last  part of the apparatus,  the  chaplet of M. Mayor would be
decidedly preferable, and better even than for the nose.   If, in order
to strangulate the polypus by means of this  chaplet, we  could not
command the mechanical addition of the winch  which the  author
uses, nor the little instrument of the same kind,  invented  by M. Le-
vannier, (Arch. Gen. de Med., t. XI., p. 407,) we might succeed very
well by tightening the two halves  of the  ligature upon  a piece of
cork, or any other solid substance.  The jointed  knot-tightener
which Bichat was desirous of substituting for the  forceps-canula of
Desault, as  it is incapable of carrying out the intentions of  the author
except in a few rare cases, is worthy of no further remark.  Nor do
I think that the knot-tightener of Ansiaux, (Clin.  Chir., 2nd edit., p
285,) or the speculum of M. Guillon, as modified by M. P. Dubois] so
as to serve as a ligature holder,  nor the seven pieces which enter into
the instrument of M. Lasserre,  (Arch. Gen. de Mid., 2nd  ser., t. V.
p. 153,) are calculated to throw into oblivion the apparatus of the an-
cient surgeon of the Hotel Dieu, which is so simple and ingenious. 
POLYPI OF THE UTERUS.
485
  V. When the ligature is properly applied, the circulation and vital-
ity  of the part below it soon  cease.  While the mortification of the
polypus is going on, the ligature little by little cuts through the pedi-
cle.  It is easily conceived, moreover, that the ligature will divide
the root so much the more speedily, according to the force of con-
striction employed, and the density, resistance and volume of the tis-
sues.  So long as the pedicle does not exceed in thickness the diam-
eter of an inch, a single ligature properly tightened will suffice to cut
through it in the space of a  few days ; but it has been  considered
when it exceeds this diameter, that it would be advantageous to per-
forate it by means of a needle with a double  ligature, in  order to
strangulate its two halves separately.  This is a  principle  to which
in  the first place,  two  objections maybe made:  1. Those polypi
which may be brought out to the vulva, and which are the only ones
which are adapted  to this  process, rarely have a  root so large as to
require this precaution.  2. Those  which  have  a  larger  pedicle,
whether  they may be brought  out or not, are all of them  fibrous
bodies, which are to be detached by means of the cutting instrument,
or  they are vegetations of a bad character, which are not to be med-
dled with.  Enormous polypi, however, have been removed by means
of the ligature.  Richter, of Moscow, (Synopsis Obstet., &c, p. 114,)
has succeeded by this means, though the tumor weighed four pounds
and a half.
  B. Among the ligature-holding instruments which have been pro-
posed, those of M. Mayor  appear to  me  to be especially worthy of
being made trial of.  These  consist of two elastic steel rods, or even
of whalebone, should we not have time to procure those of metal, and
are terminated in crabs' claws.  The ligature is adjusted in the same
way as in the forceps of Desault, and is  to be applied  around the
polypus with the  same precautions.  All that is required to disengage
it, is to draw with some force upon the conducting instrument, as soon
as the knot-tightener has reached near the pedicle to be strangulated.
With the  double tube of Levret, the two portions of the ligature are
brought too near  the polypus, to allow of its sliding with ease when
we wish to augment the constriction.  . The same remark nearly ap-
plies to all the knot-tighteners.   To introduce the ligature  down to
the root of the polypus, astraddle the left forefinger, while with the
right hand we bring its two halves out in front, as some person (Gaz.
Med., 1832, p. 720,)  has recommended, would succeed only in some
rare exceptions.   Embarrassed, like so many  others, by this incon-
venience,  M. G. Pelletan, with  a view to avoid it, has caused to be
constructed  an ingenious apparatus.   Being slightly separated apart,
in the manner of a fork, to the distance of some lines, the two branch-
es which terminate the inner  extremity of his knot-tightener,  are ap-
plied on their concavity against the root of the polypus, and scarcely
deviate the direction of the thread, with the circle of which they are
in some sort continuous.  A spring, or kind of steel band, curved in
several directions in order to increase its elasticity, being placed at
the  outer extremity of the instrument, receives the other  end of the
ligature, and constantly augments the constriction.  The elastic in-
strument moreover, may be combined with all the other contrivances,
and among others with the chaplet of M. Mayor.   As to the bifur- 
486
NEW ELEMENTS  OF OPERATIVE SURGERY.
cation of the knot-tightener, it would be attended with no inconve-
nience, unless we wished to turn it on  its axis in order to twist  the
ligature.
  C.  Before strangulating a polypus which hangs outside, it is  im-
portant to remark, that its pedicle  might possibly be formed by the
fundus of the everted uterus, and that it would be dangerous in that
case, to place the ligature on too elevated a point of the tumor.  The
decomposition of a polypus in the sexual organs, sometimes involves
consequences which we should be fortunate if we could avoid.  Thus,
the offensive odor which attends it is exceedingly disagreeable, both     «
for the patient and for those who are about her.   When the  polypus
is of a very large size, and the temperature of the weather very ele-
vated, this odor in fact may be  so excessive as to be  insupportable.
The putrilage, moreover, which results from it, irritates the vagina
and vulva, and  may, if it is absorbed, give rise  to infection of the
whole system, or to  a fever of bad character.   Should it be found
impossible to  bring the tumor  to the outside, we must content our-
selves with combatting these inconveniences by means of the ordi-
nary  cleansing  resources, by  simple  injections with mallows or
sweetened barley water, those of decoction of bark, or what is better,
with solutions of the alkaline chlorurets; but when the pedicle is very
low down, 01 when by means of moderate tractions we can make it
descend without occasioning too much pain, it is more  expeditious,
and certainly less dangerous, to excise  the whole mass below the
ligature than to leave it to itself.  M. Demaziere de Bergues, (com-
municated by the author, August  16,  1837,)  by operating  in this
manner, after having made use  of  the forceps to depress a  polypus
of two pounds and a half in weight, in  a woman 41  years of age,
succeeded perfectly.
  D.  Levret  has contended  that after the ligature, the mortification
extends to the  union of the polypus with the uterus, even  though
the constriction may have been made a little below, and that these
tumors, when  once  strangulated, almost  always become detached
at the same point as the umbilical cord  does in the infant, what-
ever  may be the part at which the ligature has been applied.  This
idea appears  dangerous to Boyer.  In  fact, if it were erroneous, it
might involve serious consequences in  practice.  If we adopted it,
it  would  be a  matter of  little  consequence whether we applied the
ligature exactly on  the upper  part of the pedicle or at some dis-
tance below.   Now, as  it is generally more easy to apply it lower
down than higher up, and  as  some persons, moreover, mio-ht be
fearful if they adjusted it  higher up, that they  might wound° some
portion of the  tissue of  the  uterus, the  ligature would  in many
instances  be placed  in such manner as  to leave a portion  of  the
polypus in the  organs.   If on  the other hand it be  true, as Boyer
affirms, that vitality does not cease in  the  tumor, except  in  the
part below that which is embraced by  the ligature,  this latter, if
we do not wish to  run the risk of a  return of the disease, ou'^ht
always to be applied upon the most elevated point of the  morbid
production. The opinion of Levret is based upon facts, and M. Gen-
seul has defended it by adducing cases in support of it.   Moreover*
from  what we know of the laws of the organism, there is no reason 
POLYPI OF THE  UTERUS.
487
why this process may not be compared to what takes place at the time
of the separation of the umbilical cord. All that is requisite is, to un-
derstand ourselves on this point.  The mucous polypi, or those in
which numerous vessels are distributed, and which  are  evidently
continuous with the tissue of the uterus itself,  are not compatible
with the theory of Levret, which in my opinion is applicable  only to
those which constitute actual foreign bodies in the midst of the organs,
or still more to those polypi which are purely fibrous or lardaceous,
and which  are destitute of any appreciable vascular circulation.  I
have seen more than an inch  of the root of a fibrous polypus come
away a  long time  after the separation of the ligature, and putrefy
in  two  other  cases to a considerable distance  beyond  the point
where it was excised.   This phenomenon is so much the less surpri-
sing, from the  fact, that certain pdlypi dissolve, and  ultimately dis-
appear spontaneously in the womb.  A fibrous body of the size of a
nut, which I had ascertained to exist in the neck  of the uterus, could
be no longer found at the expiration of six months, though nothing
had been expelled from the genital organs.   If it should be objected,
that I might have  been deceived in  this case,  I would add, that in
a woman who  came into La Charite in August, 1838, to be operated
upon, the polypus gradually disappeared  under our eyes, and that the
patient having  died of peritonitis, we were enabled by the autopsy
to detect the root in the body of the uterus itself. Duges and  Mdme
Boivin, moreover, have noticed similar facts.

                        § VI.—Excision.

   The ancients, more daring than surgeons of the  last century, fre-
quently  had recourse  to  excision  of genital  pol)-pi.  Philotenus,
Aetius, Moschion, &c, evidently had  reference to this method when
they recommended the removal by means of the cutting instrument,
of varicose or hemorrhoidal excrescences of the uterus.  F. ab Aqua-
pendente made use for this  purpose of cutting hooks, which  he has
greatly eulogized, and  the extremity of which made in the manner
of scissors, exempted him from  the necessity of previously drawing
the polypus  to the outside.  Though the attention of practitioners has
been occasionally directed by authors to  the subject of excision,  and
that Tulpius, (Bonet, Corps de  Aled., t. IV., pp. 29, 31,) Water and
Fronton, the latter cited by Levret, relate cases in its favor, it has
nevertheless not yet succeeded  in triumphing over  all prejudices.
Boyer, who  states that he employed it in one instance with success,
and who does not appear to be disinclined to yield it the preference,
does not, however, venture to formally recommend it as  a general
method.  The objection to it is that it exposes to hemorrhage and to the
danger of wounding the rectum, bladder, vagina, and even the womb,
and that  it is a  more difficult process than the ligature.  The  wound.
itself which it must necessarily occasion, has alarmed many surgeons,
who apprehend tljat  inflammation may be thus  produced  in  the
uterus, or that there may ensue a suppuration or an ulcer, which it
would be found difficult to cure.  The investigations and dissections
which I have had it in  my power to make, and which are in accord-
ance with those undertaken by M. Hervez de Chegoin, have demon- 
488
NEW ELEMENTS OF OPERATIVE  SURGERY.
strated to my satisfaction that fibrous bodies, properly so called, may
be excised without the slightest inconvenience.   In no cases, in fact,
are they adherent to the uterus  by a pedicle  containing large sized
vessels.  The layer of the uterus, usually very attenuated, which
serves as their investment, is nothing more than a simple envelope,
which we have nothing more to do than  to incise to effect  the enu-
cleation of the pedicle with great ease, either by means of the fingers
or the handle of a scalpel, in the same way as if it were a lipoma or
sub-cutaneous cyst.   As  to homogeneous,  hard grayish  tumors,
which are continuous  with  the  tissue of the  uterus,  the section  of
their pedicle also  is not of a nature to give rise to any dangerous loss
of blood, if I may judge at  least by those which I have met with in
the dead body, or which I have had occasion  to remove during life.
Nor, in the third place, can I conceive why fibrous masses caused by
a partial hypertrophy of the organ, should be calculated to give rise
in this respect  to the slightest  apprehension.  It is also difficult to
comprehend  how the removal with the cutting  instrument of those
small mucous soft  tumors mentioned by M.  Berard, and  which I
have several times successfully extirpated, or how any other polypous
growth  which can be  attacked  by the ligature, could any  more in
reality give rise to a dread of this accident. There are, therefore, no
other tumors than those reddish  bleeding vegetations,  occasionally
painful, but rarely pediculated, and which have been mentioned above,
which might render excision improper;  but  the ligature  to  them
scarcely answers any better purpose, for we have  to rank  these
among those unfortunate diseases which nothing can relieve, and  to
which may be applied  with too much justice the designation of noli
me  tangere.  Dupuytren excised  all  the uterine polypous tumors
which he was called upon to treat, and in one case only  did the flow
of blood appear to him so considerable as to require some  particular
attention.   M. Hervez  de Chegoin relates numerous facts which are
full as conclusive.  M. Villeneuve, M. Lejeune, and a  great number
of other practitioners  have also published various operations of the
same kind, which have been no less successful.   In Germanv MM.
Siebold and  Mayer have  published a memoir  which  proves that
excision, which had been long since adopted by them in the hospitals
of Vienna, has  been attended  with successful results  of the  most
remarkable character.   Finally, I may be permitted to add  that out
of twenty operations  for polypus, which up to the present time
(April, 1839)  I have had occasion to perform with the cutting instru-
ment, not one of them has occasioned the  slightest disturbing*hemor-
rhage.
  A.  Operative Process.—The  articles consist of one of Museux's
long forceps, an ordinary bistoury or simple scalpel,  together with
lint, certain astringent preparations in case of necessity, and also
linen  as in other capital operations.  If, however, the  tumor should
be of large size other instruments  might be required; such, for ex-
ample, as  forceps, sharp hooks, or,  as I have  sometimes used, lon«
and strong double erignes, somewhat curved, in t)rder to acco'mmo°
date themselves to the form of the parts.
  I. In  ordinary  cases, the right hand introduces the forceps, shut
up, into the vagina, and does not open them  to grasp  the tumor ex 
POLYPI OF THE  UTERUS.                  489
cept so fai as the fingers of the left hand  protect and direct their
hooks.  B}  means of gentle tractions, judiciously made, the morbid
production is then gradually made to descend.  If the mobility of the
uterus is such as to enable  us to bring out  the pedicle with ease, its
section may then be readily made by means of any cutting instru-
ment whatever, while an assistant carefully holds open the lips of the
vulva.  When, on the contrary, the polypus does not  yield, the sur-
g3on, without allowing it to ascend, must proceed with the point of
a straight bistoury, to divide it at its most contracted portion, always
following the instrument with the  fingers of his left hand, which
should be kept in the vagina.   I had occasion, in a young lady, to
operate for a polypus as  large as a turkey's egg, which was planted
on the interior of the neck, and which, after having got down as far
as into the vulva, appeared to be disinclined  to descend any more.
While M. Cottereau, physician of the patient, retained it in the pel-
vic strait, I introduced the  fore and middle finger of the left hand to
the os tincae, and then, with the right hand,  I glided in, as high as the
upper part of the vagina, and between the polypus and my fingers, a
bistoury wrapped in linen, and by means of which I readily detached
the tumor.  Not a drop of blood flowed, and this lady might have re-
sumed her usual occupations on the third day after.
  II. If the polypus, on account of its size, should prevent our  pro-
ceeding in this  manner, we might make  use  of a bistoury slightly
curved flatwise, or  a  pair of scissors of the  same form.  In cases
where it  might appear to  be dangerous to make tractions on  the
womb, the species of forceps  terminated  by a strongly curved  ex-
tremity and slightly notched,  and having a  cutting edge like  the
tenaculum of J. Fabricius, and  which has been used  by Lobstein in
more than one instance, would prove a valuable resource.  It was
with  the same object  in view that M.  Mayer contrived long and
strong scissors, curved in the shape of an  S, by means of which he
could  detach  the tumor at whatever height it was  situated.   The
scissors, however, made use of by Boyer and Dupuytren, which are
equally long  and very strong, and which have only a simple conca-
vity on one of the sides of  their blades,  would accomplish the same
result  full as  perfectly.  They have, moreover,  another  advantage,
viz., that of detaching the polypus little by little from the walls of the
vagina when it  has  contracted adhesions with them, and  before we
bring it down and divide its pedicle, as would  have been required in
the case noticed by M. Berard, (Arch. Gen. de Med., t. II., p. 88,)
as the tumor here was attached to the vagina by one of its roots and
to the interior of the uterus by the other.
  III.  If the tumor  should not  be separated from the organic wall
upon which it has originated except by a groove, in place of having a
pedicle, and if this body were fibrous, we must not, on that account,
suppose ourselves obliged to carry the  instrument into the deepest
part of the  groove.  In such cases, in  fact, provided we incise a
little  above  the greatest diameter of the  polypus, and can give a
certain extent to the incision and divide the entire layer of natural
tissue which  envelopes the morbid  production, nothing more is re-
quired to enable u&, oy means of the fingers, the handle of the instru-
ment or simple tractions, to  detach the tumor in the'same way that we
  vol. in.                      62 
490
NEW ELEMENTS OF OPERATIVE SURGERY.
 would  separate a kernel  of fruit from the parts which envelope it.
 The flaps which are left by this enucleation, either retract and cica-
 trize by shrinking upon themselves, or are in part destroyed by means
 of the suppuration.
   IV. Uterine  polypi are  sometimes of so large a size  that they
 completely fill up the whole of the vagina, and even ascend  as high
 as into the hypogastrium or iliac fossae.  Baudelocque  states that he
 saw one whose lower half occupied the pelvis, while the other made
 a marked projection above the  upper strait.   He was enabled to
 strangulate the  first portion; but when it had separated, Louis was
 not willing that they should attempt to reach  the other with  the for-
 ceps.   The woman died, and Baudelocque asserts that  it would have
 been practicable to  extract the second portion of the  foreign  body
 full as well as the first.
   It is for cases of  this kind that the same author  recommends the
 use of the forceps, which Herbiniaux had employed before him with
 entire success.  Since that period, it has  been used by M. Deneux,
 Murat, and M. Hervez de  Chegoin, with all the benefit that Baude-
 loque had  anticipated  from it.  At the present time, when we  have
quite correct ideas on the nature of these large sized polypi, we could
undertake their extraction  with so much the greater confidence, from
our not feeling ourselves any longer under the  necessity of having
 recourse at  the same time to the ligature.  After all, the forceps is
not the only instrument, nor is it always the  best which would  be
indicated in such cases.
  V. In the month of September, 1830,  1 was  sent for to Bergues,
by M. De Mazieres, to attend a lady who had an enormous fibrous
 tumor of the womb, and which made a  projection above  the  pubis
 and filled up the vagina.   Though resistant and  very elastic,  it could
 be so easily depressed that the prongs of the forceps constantly  tend-
 ed to slip either in front or behind.  I preferred grasping its  apex
 with Museux's long forceps, and then applying two strong  erignes
 with double  hooks above  its thickest portion,  one on each side, and
 plunging them  deep into  its  tissues.  Being  thus  grasped by four
 points  at the same time,  it was gradually brought down into the
 lower strait by means of  well regulated  tractions.  The perineum,
 which had to  be incised  posteriorly, resisted for  a long  time, but
 finally, ascertaining with my forefinger that the pedicle of the  poly-
 pus was powerfully stretched, I directed  upon it a straight bistoury
 wrapped  in linen,  when  an  incision of a  few lines enabled the
 elasticity  of the parts  to complete the  operation; no hemorrhage
 took place,  and notwithstanding the marasmus  and  exhaustion to
 which the patient had been reduced, her health has been completely
 re-established.  I have operated with the same success in a case in
 every respect similar, and who was a patient of M. E. Moulin.  In an-
 other woman the polypus  was so voluminous  that I could not in any
 way bring it to the outside. M. Chassaignac suggested to me  the idea
 of removing a thick cut from it in  the same way as we would a slice
 of melon.   Having thus  brought  it down I detached it in the same
 way  as in the preceding  cases.   There  are  cases however where
 the tumor is so situated that nothing appears capable of depressing
 it  A woman 36'years of age, was sent  into my department at the 
POLYPI OF THE UTERUS.
491
 Hospital of St. Antoine, by M. Kapeler.   Her tumor filled up almost
 the entire pelvis, and  formed a considerable  projection above the
 strait.   M.  Marjolin,  M. Kapeler and  myself,  decided that we
 would  endeavor  to  extirpate it through  the  natural passages.  I
 grasped it three times with an ordinary forceps, and three times my
 efforts to make it descend proved unavailing.  Being then apprehen-
 sive that I would unnecessarily aggravate her sufferings,  I deemed it
 advisable to abandon the patient to the natural consequences of her dis-
 ease.  She died at the expiration of some months.  At the autopsy, we
 found a fibrous body without any pedicle, and mostly transformed into
 putrilage, and having  its root in the tissues of the left wall of the neck,
 from which moreover it could easily be detached after having incised
 its layer of natural tissue. Another tumor, which was as large only as
 the two fists, and united at one of its sides with the preceding, occupied
 the right side of the uterus, and was also  found enveloped by a thin
 layer of this  organ.   These two masses, whose base was almost as
 large as their greatest diameter, and which were of larger size above
 than below the strait, could not  be grasped  with sufficient  firm-
 ness by the forceps to enable  us to depress and remove them; but
 the dissection proved to us, that  notwithstanding  the apparent ex-
 tent  of their  adhesions, their  excision  by  enucleation would  have
 been practicable,  if by any means whatever we  could  have  made
 them  descend to  the lower  strait, or  could have applied  the bis-
 toury upon any point of their circumference.
   VI. As  these descriptions of polypi cannot be lacerated but with
 much difficulty, it  would be advantageous, when we have succeeded
 in  making them protrude at  the vulva, to  insert  through them, by
 means of a long curved needle, having a handle and pierced near its
 point, a strong ligature of waxed thread, which should  be  shaped into
 a noose, and which would enable  us to  make traction  upon  them
 without causing as much embarrassment as the other instruments.
 When the  tumor is of an equivocal character, or  when it should ap-
 pear practicable by seizing it with  a  forceps to make it  descend so
 far as to enable us to  pass our finger around the pedicle, or when, as
 in the cases cited by Levret  and Eschenbach, we perceive arterial
 pulsations in this pedicle, or when, notwithstanding what I have said
 in the remarks above, the hemorrhage  might still  be calculated to
 produce alarm, there would be nothing to  prevent  us from applying
 in the first  place, before making the excision, a ligature as high up as
 possible, as  is recommended by M. Mayer, and as has  been  prac-
 tised by M. Demaziere.
  VII. If the tumor is still entirely enclosed in the womb, and if we
 have been enabled to  satisfy ourselves that it is alone and  that  no
others exist in the tissues of the organ, beyond the aid of  surgical re-
sources, we may still quite frequently have  it in our power  to«reach it.
 To secure the neck of the uterus by means of a number of Museux's
forceps, to  depress it.  and to enable us more readily to explore, grasp,
and remove the polypus, is a pernicious practice, which would be not
worthy of being mentioned, if a surgeon of Paris had not conceived
the idea  of giving  it  the preference over  every other.   It is infi-
nitely better in such cases to imitate Bonnie, and to dilate the  parts
at first before disengaging the polypus, or even to effect the debride- 
492
NEW ELEMENTS OF OPERATIVE  SURGERY.
 ment of the neck on one or several points, as Dupuytren has done in
 some instances.
    VIII. Process  of the  Author.—I  feel moreover satisfied  that  a
 good pair of erigne forceps, guided  by the finger, will almost al-
 ways succeed in such cases without any great degree of difficulty,
 in embracing  the head  of the polypus, whether the debridement
 should afterwards seem  to  be  indispensable, or whether  the finger
 may in the first place reach the root of the tumor; I apply as  high
 up as to this part, either the long curved scissors, or the blunt knite,
 which is also curved.  Supporting  the forceps with the finger, while
 an assistant  makes gentle traction  upon them, I am enabled  to  de-
 tach the polypus  without  any difficulty.  I was enabled in  this man-
 ner, with M. Pailloux to assist me, to remove in 1837, from a lady,
 an enormous fibrous mass which had passed into a state of putrilage
 in the uterus.  In adopting the same  method, I  excised without dif-
 ficulty at La Charite, in  1836, 1837, and 1838,  a sarcomatous  poly-
 pus of the size of a  nut, afterwards a  fibrous polypus, which was
 yet still less, and finally  a polypus as large as an egg, in three dif-
 ferent women.   This is a method, moreover, which I also apply to
 polypi which have escaped  from the  neck, and which  may be seized
 in the vagina.  A patient of  M. Dufrenois, and  several patients of
 the hospital, were operated upon in this manner without the slightest
 difficulty.  As we are enabled by this process to avoid all tractions
 upon the uterus, the operation is  thereby evidently rendered less pain-
 ful and less dangerous.
   B.  Subsequent  treatment.—After the excision, the treatment  re-
 quired by the patient is confined to injections, which are first emolli-
 ent, then detersive, and finally slightly desiccant.  If contrary to all
 expectations  a hemorrhage should" supervene, astringent injections or
 pledgets of lint saturated with oxycrat, eau de Rabel, or solution of
 alum,  or  sprinkled with  colophane or any  other  styptic  powder,
 would, as I conceive, speedily arrest it.  Tamponing also would  be
 a last resource, which must not be omitted after having in vain made
 trial of other means.  The cure  is usually rapid, and°the woman is
 sometimes re-established in less than 15 days.  But serious  and even
 fatal accidents may also result from the excision of a polypus, how-
 ever small it may be.  A lady had one  of the smallest description.
 She was operated upon  and death took  place three days after.  As-
 sisted by M. Cartault, I  excised one which  did  not exceed the size
 of a cherry, but the patient nevertheless died of peritonitis  in  eight
 days.  A fatal hemorrhage closely followed upon an operation  of as
 trivial a character in  a  case  which has been related to  me bv M
 Marjolin.  In two instances I  have seen serious symptoms of phlebitis
 or of suppuration in the pelvis, after the removal of a polvpus  from
 the uteris.   As a general  rule, however, it is one of those operations
 in  surgery which  succeed  the best.

                    [polypi of the  uterus.

  One of the most important  circumstances connected with fibrous
 polypi of the uterus, growing upon  the fundus of the womb and
within that organ, is the difficulty attending its diagnosis from preg 
POLYPI OF THE UTERUS.                  493
nancy, or prolapsus, or eversion of the uterus when the tumor is very
large.   It then, as is remarked by Dr. Bullen, in an excellent memoir
on Polypoid growths of the uterus, (Dublin Med. Joui n., vol. XXV.,
1844, p. 407, &c.,) occupies the whole of the womb.   In a remarkable
case of this kind in a woman aged 50, labor pains and hemorrhage
came on, and  the tumor  having descended  into the  vagina was re-
turned  by the midwife, on the supposition that it was a prolapsus of
the uterus. Its appearance, according to Dr. Bullen, was in many
respects similar to a  prolapsed uterus!  It  may be  mistaken for a
prolapsed uterus when the tumor has only partially descended  into
the vagina or  to the vulva, because  not only its general  shape natu-
rally corresponds  to the  cavity which it fills,  but also the mucous
membrane which  lines it, being continuous with that of the  uterus,
presents in a morbid state the same aspect as the latter.  For exam-
ple, it is extremely vascular, and several large veins filled with blood
can be  distinctly seen ramifying through it, while upon the surface
are irregularities, and also a marked indentation that give it quite the
appearance of the  os tincae.   The*  deception, moreover, of  an im-
 pregnated uterus  will  be added to this  misapprehension when the
polypus is  replaced in  the vagina, as the tumor is then felt in the
hypogastrium above the pubis, of the  size and shape of the womb in
the sixth month of pregnancy.  But when the polypus drags down
and inverts the uterus  by its weight, that is, turns the latter inside
out  and brings it completely without the  vulva, a mistake  can no
longer  exist,  as we should think, because  then the counterfeit os
tincce still  remaining, would manifestly, prove  that the uterus itself
could not have prolapsed to so great an extent; while the  attach-
ment of the polypus to the everted fundus would also then be neces-
sarily defined  in a clear manner.  To make a correct examination,
Dr. Bullen recommends Prof. Simpson's uterine bougie, to be passed
up  between the uterus and tumor, taking care first to replace the
uterus in situ.
  The tumor in the case in question  was brought as far as conve-
nient without the vulva, when a ligature was placed around its broad
base, close to  its attachment to the fundus of the  womb.   Forty-
eight hours afterwards, in consequence of the dangerous reaction,
pain, abdominal tenderness, offensive discharges from the vagina, &c,
it became  necessary to proceed immediately to the delivery of the
tumor by Levret's forceps, and before the  ligature had had time to
cut its way through it.  To meet this difficulty torsion was  used
with the forceps to a very considerable extent, by which means the
polypus was brought away.  It was fibrous and larger than a child's
head,  and  weighed nearly two pounds.  An immense quantity of
fetid liquid, which had been pent up, was thus also enabled to come
away, which gave  great relief.  The ligature on the remaining neck
of the polypus came away two or three days afterwards.  Though
it is not so  stated, the inference is that this patient recovered.
  In remarking upon this case and treatment, Dr. Bullen judiciously
points out the necessity of forcibly abstracting the tumor by torsion,
as above described, as soon  as there are any manifestations of the
dangerous  description mentioned.   The retention  of  the  natural
mucous  and sanguineo-mucous discharges  of the  uterine cavities 
494
NEW ELEMENTS OF OPERATIVE  SURGERY.
 and passages, must  necessarily endanger their absorption, which is
 the chief thing to be dreaded, and  much  more so than the imme-
 diate inflammation radiating from the place of the ligature.   Cases
 in proof of this are given, and one (Provincial Journal, 1844) where
 the polypus being left in the womb, caused engorgement of the fal-
 lopian tubes with pus, suppuration and gangrene of the tissues near
 the right ovary, sloughing of the uterus, adhesions of the peritoneum,
 and, in fact, all the  local and# constitutional  phenomena of typhoid
 fever and uterine phlebitis  in' their  most  formidable  shape.   The
 polypous tumor was never abstracted, and lay .oose  and detached
 in the vagina,  being the  twelfth day from the operation.
  Dr. Bullen points out another very important circumstance in con-
 nection with the difficulty of the diagnosis in these polypi.  Thus the
 investing membrane of the tumor, by the deposition of coagulum lymph,
 will be found to have become closely adherent to the lining  mem-
 brane of the dilated uterus itself, as well as  to portions of the vagina,
 with which it may be in contact.   This state of things may still more
 strongly incline the surgeon to suppose at  first that the disease in
 question is in fact a prolapsed uterus; and  should  the  tumor slough
 and separate, a more gross delusion may arise, and lead to the sup-
 position that it is the uterus itself which has been detached.   The
great purpose of the ligature to polypi in the uterus, is, as  we per-
ceive, not to wait  for its action until it has cut through the enormous
pedicle, but in order to prevent hemorrhage when we proceed to ex-
tract the tumor by torsion.  As an evidence of the danger of hemor-
rhage,  in immediate excision of uterine polypous tumors, Dr. Bullen
instances  several  in which he has seen  it  occur  after snipping oft'
merely those forms of this tumor which are cystic, and  united mere
ly by a slender pedicle to some part of the  lining membrane of the
cervix  uteri, of which membrane these cystic polypi, which are filled
with a  gelatinous  fluid, appear to him to be nothing more than a sac-
culated prolongation  or  hypertrophy.   The actual cautery only, he
says, will arrest  the hemorrhage, but this  is  what will scarcelv be
permitted by the patient.
  There is a third description of polypi of the  uterus, which are ma-
lignant, and terminate fatally, and  yet are not, in Dr. Bullen's  opin-
ion, cancerous.  These are what he  terms  malignant,  granular, or
tuberculous polypi, sometimes  called the cauliflower  polvpus,  and
which are distinguished  by their great  vascularity and  tendency to
profuse hemorrhage, producing great  exhaustion, but  unaccompa-
nied with pain.  In their ultimate development, they assume all  the
characters of Carmichael's malignant parasite.  Yet they are totally
distinct, Dr. Bullen says, from true carcinoma of the uterus, in which
latter no one can  mistake the  peculiar  well-known acute, hot and
lancinating pains,  and finally the terrible, though slow destruction of
parts from the rat-bitten-like, jagged ulcerations, &c.  Nevertheless
these cauliflower forms are frequently hereditary, or at least connect-
ed with a constitutional diathesis.   Thus he knew three married sis-
ters of a highly respectable family near Cork,  (Ireland,) who all suc-
cessively died of this hemorrhagic  form of polypus, on  reaching the
age of 43 years.  Two of the three had children.
  In another, an extreme case of this kind, in  a married lady, aged 
POLYPI OF THE UTERUS.
495
30, Dr. Bullen, from the painful and distending pressure made by the
growth of the tumor, which finally filled up the entire uterine cavity,
and thus of itself arrested the hemorrhagic  discharges, was obliged
to have recourse to the silver wire ligature, applied through the can-
ula.   He thus brought away a basin full of the morbid growth, but
it was at the sacrifice of an immense and  dangerous loss  of blood.
The surface of the substance was rough and granular, and  its  tex-
ture very friable, and easily rubbed down between the fingers, show-
ing a reticulated appearance  like sponge.  It would be well,  as we
think, in such cases, always to ligature a small portion at first, and
bring it  away, were it only to aid the explorations  and  diagnosis.
Dr. Bullen remarks that there were also  lobulated aggregations of
small whitish opaque  bodies, manifestly tubercular, thickly scattered
throughout the  extent of this  morbid mass, and interspersed with
distinct cavities  containing transparent hydatids.  The size  of the
mass was greatly reduced by its removal, showing that its great bulk
was  chiefly  owing to the  quantity of blood  which it  contained.
However,  this distressing disease again returned, and she sunk from
loss of blood, both her mother  and aunt having died with  the same
affection, before they reached the age of 40.  Whatever be the name
given, we cannot but look upon such forms of polypus, if that gene-
ric designation in fact be admitted, as purely of thejfungus hcematodes
character, such as are found in the breast and other regions. The ap-
pearance of  hydatid cysts and encephaloid deposites in the so-called
cauliflower polypi, when they have reached their ultimate degeneres-
cence, does not make it necessary  to exclude them from fungus he-
matodes, for however old fashioned this word, its import is well un-
derstood, and such bleeding, hypertrophied, and almost  painless tu
mors, are much easier recognized by these familiar epithets, than bj
any presumed analogies to the more vague descriptions of disease
known under the names of erectile tumors, or  vascular sarcoma.
Dr. Bullen, however, contends also that these carcinomatous polypi
differ in  toto, as they doubtless do,  from the florid warty vegetations,
which are often seen upon  the external lip  of the cervix uteri ac-
companying  obstinate leucorrheas and certain forms of syphilis. [Ra-
ther say, mercurialized syphilis.  T.]  Dr. Bullen considers this form
of polypus as decidedly malignant, but as not necessarily requiring
carcinomatous ulceration or symptoms of true cancer to make them
fatal.  In the beginning, excision of the neck of the uterus, as this is
their special locality, might answer; but then  the disease  is so insi-
dious that it  is completely marked by (i. e., confounded with)  mo-
norrhagia.   In considering the point, whether in their advanced stage
excision  of the uterus would be justifiable, Dr. Bullen is  averse to it
under almost any circumstances, and naturally reverts to the fact of
the danger of such an operation, and  the growing aversion to the
employment of the knife as a curative agent in any form of malignant
tumor.   Certainly experience has given us too  much reason  to dis-
trust its value under such circumstances, especially when we reflect
that daily accumulating observations go  more and more in confir-
mation of the ancient opinion, that malignant tumor depends on  a
constitutional malignant diathesis, always existing, but developed at
a certain period; or as Dr. Bullen says," growths, essentially malignant 
496
NEW ELEMENTS OF OPERATIVE  SURGERY.
are malignant ab initio, or from their  first  development  in the sys-
tem."  A fortiori, we would  say to this surgeon, that  we  are car-
ried back" for our only refuge here, as well as in various other de-
partments of the art, to conservative surgery and  the medical  treat-
ment of local as well as constitutional affections, hitherto deemed to
have been the monopolv of the scalpel.                          .
  Dr. Bullen also quotes the recent report of Dr. Regnoli to the Sci-
entific Congress of Italv, to show that the average duration of  life is
longer in such cases, where  they have been  let  alone, than where
extirpation  or the knife has  been appealed to.   For out of 250 in
whom  cancerous  formations had  been extirpated by the  knife,
scarcely  twenty had survived  three years.
  The discussion on tumors at Paris, which we  have elsewhere  given
at length in  this volume, (see supra,  under Tumors,) also all resolves
itself into this one great conclusion,  from which there  has been  but
little dissent.  Of this result M. Cruveilhier, who first  led off in this
important investigation, has  much  reason to  be  proud, when he
reflects how great an acquisition this unanimity has already brought
to conservative surgery, and to the shielding of human life from the
inhuman  mutilations of the knife in the hands of reckless and ig-
norant persons.
  Dr. Lever of London (Practical Treatise on Organic Diseases of
the  Uterus. fyc, which received the Fothergillian medal in 1843,) has
found, contrary to the general remark, as many uterine polypi that
were sensitive, as those that were not so.  He  considers both polypi
and fibrous  tumors, which he makes distinct, more frequent in un-
married, than in married persons.
  Mr. H. Oldham (Guy's Hospital Reports, April, 1844) has  been
surprised to  find, that on injecting ordinary pediculated fibrous polypi
of the uterus, the arteries were  not only of large  size, but far  ex-
ceeded in their number that of the veins in the tumor. The abundant
hemorrhages which such polypi frequently occasion, especially where
they are  complicated with pregnancy, when they may  lead to dan-
gerous mistakes, is thus easily accounted for.   The uterus itself  has
been ligatured for a large  polypus, and thus actually excised!   Mr.
Rigby informed Mr. Oldham of a  case in which  a fibrous polypus was
tied, when on the following  morning  the  surgeon finding anothei
tumor above his  ligature, also tied that.  After the  separation of this
supposed second tumor, a cicatrix was found above at the upper part
of the vagina, but the womb  was gone !  Polypi consisting of  small
cysts, containing viscous matter, are, Mr. Oldham thinks, abnormal
developments of the ova of Naboth,  or of uterine follicles.  To these
follicles in the neck  of the womb he also  ascribes a  new form of
uterine polypi, which  he  calls canaliculated,  having  a number of
elongated canals  running  through their substance  and opening by
quite large orifices on their surface.  Most polypi he considers discon-
nected in their origin with organized clots of blood, but as growths
from the  substance of the  uterus  itself.   When  polypi  in the womb,
by  their  hemorrhage during  parturition, give  rise to  apprehension,
they are  to  be ligatured or exsected immediately.
  M. L. Boyer (Arch. Gen.,  May,  1844) recommends a new knot-
tightener, or rather  sawing  ligature,  for  exsecting polypi of  the 
CANCERS OF  THE NECK  OF THE UTERUS.
497
uterus.  He calls  the process sercision, (from  serra,)  and £he two
ends of the ligature, after this is adjusted, are drawn in  such manner
in opposite directions by a saw-like  movement,  similar to certain
sports of boys, that the pedicle is rapidly cut through, and this tear-
ing process (a species of torsion) may, he  thinks, even prevent as
much hemorrhage as in ordinary cases.
  A pediculated polypus in the womb, to which  a part of the
placenta had  become so firmly  adherent, with perfect inosculation
of their respective vessels, that the cord  was  broken off in an
attempt to remove the secundines after the birth of the child, was
effectually detached by M. Aubinais, (Gazette Medicate, Paris, Sep.,
1844,) by twisting the polypus upon itself, by which means this
foreign body,  which had not it  appears interfered with, but  rather
shared  in the process of utero-gestation, was immediately brought
away  together, with  its attached placenta.  (See also  Cormack's
Monthly Journal, March, 1845, p. 243.)
  A large polypus of a fibrous character was recently expelled from
the uterus (Provincial Med. and Surg. Journ.; also  Edinb. Med.
and Surg. Journ., Oct. 1, 1845, p. 283)  by contractions of the organ
artificially brought on by ergot of rye.  T.]

      Article X.—Cancers of  the Neck of the  Uterus.

  Amputation of the neck of the uterus is one of  the acquisitions of
modern surgery.   Osiander is the first person, who  about the close
of the last century, distinctly recommended it, and  performed it in
1801.   Tulpius, to whom M. Tarral  ascribes the honor of this ope-
ration, does not appear to me to be entitled to it.  The sarcomatous
tumors which  he speaks of were evidently  polypi.  We  no where
find that he in  reality contemplated exsecting the apex of the womb
itself. Lazzari, who claims it in behalf of Monteggia ; and Baudelocque
who ascribes  it to Lauvariol, have, in  my opinion, fallen into the
same error ; nor have I had it in my power to ascertain that Andre-
de-la-Croix and Lapeyronie did in reality perform this operation, as as-
serted by M. Tarral.  All that we can say is, that Wrisberg had recom-
mended it in 1787, and that several persons had certainly performed
it by chance, before any one suggested doing so designedly.  The ob-
servations of Osiander were no sooner known in France, than Du-
puytren hastened to adopt the ideas of the practitioner of Gottingen,
and to submit  them to repeated trials.   M. Recamier was not long
in pursuing the same  course ;  so that in  1815, the excision  of the
neck of the  uterus  had  already become among us, an operation in
common use.   At the present day it has been performed so great a
number of times, and by so  many different persons, that it would be
wholly useless  to enumerate the cases.

                        §  I.—Indications.

  The difficult point  is  to  establish the  indications clearly.   The
elongation of the neck from simple hypertrophy, being an infirmity
rather than a  disease, does not require  it under  any circumstance.
Excoriations,  ulcers, and syphilitic vegetations, not being incurable
  vol. in.                     63 
498
NEW ELEMENTS OF OPERATIVE SURGERY.
 in their nature, also, do not require it.   The  same remark applies to
 indurations and  to lumps (bosselures) that are not  painful, whether
 they are accompanied or not with chronic tumefaction,  and which
 are'so frequently seen in women  between  the ages  of  30  and  40
 years.  It is not allowable, therefore, to have recourse to  it except in
 clearly ascertained cases of cancerous degenerescence.  But it is pre-
 cisely  in this point that lies the difficulty of the question.  In fact, so
 long'as the cancer is not ulcerated, or does not present itself under
 the aspect of a tumefied mass  in  the upper  part  of the  vagina,  its
 diagnosis is extremely difficult.   The hardness, or natural consistence
 of the  neck, the varieties that it presents in size, prominence,  density
 and form, according to the age and various conditions under which
 the woman may have  been placed, exact in  the first place, a great
 deal of skill to prevent  our  sometimes  apprehending affections of
 which  there is not the slightest trace.  Then again,  how  can  we be
 certain that we may not be deceived in respect to the nature of a
 lesion so profoundly situated in the midst of a structure so compact,
 and  one  containing such a variety of elements ?   This  is not all:
 though the presence of a cancer may be  unquestionable, we  have
 still to  determine  its limits.  Now it is  rare that  all doubts  on this
 point are dispelled before the  disease has advanced very far, and then
we can scarcely ever be  certain that the neck alone is affected, and
that the body of  the  uterus is not already more or  less  implicated.
The surgeon therefore, is constantly placed between two difficulties :
 1.  The fear of removing an organ which is not diseased, and of unne-
cessarily performing a painful and  dangerous  operation; or, 2. That
of removing only a portion of diseased structure, the remains of which
will inevitably result in death.  The natural  conclusion from these
remarks, is, that  the formal proposition to amputate  the apex of the
womb, should be rarely decided upon, and that it is not to be wonder-
ed at that we should still  meet with intelligent practitioners who with
Wenzel and Zang, seriously ask the question whether it can ever be
advisable.  Since the question when this disease exists in  the  breast,
has been deemed proper, what are the  advantages of extirpation, it
would be difficult in fact that the same question should not be put when
the subject under consideration is the uterus.   The reply, therefore,
that  may be made, is this, that while  we admit it to be reasonable to
extirpate external cancers, there  would be  nothing improper in ap-
plying  this operation to cancers of the genital organs when they are
under favorable conditions.  It is a consolation to know that in these
last cases  the disease remains for a long time local, and that  it is in
reality  less liable to repuUulate on other points than in any other re-
gion.  I do not, therefore, for my own part, consider that this opera-
tion  ought  to be  absolutely proscribed.  Better undertake it  than
abandon the woman to a certain death, in every case where the ex-
tent  of the disease leaves room  to  hope  that we may  remove  it
entire.

                             § II.

  The  neck of the uterus may be attacked by three very different
descriptions of cancerous degenerescence.  Sometimes the affection 
              CANCERS OF  THE NECK  OF THE UTERUS.          499

proceeds by ulceration from its borders, or from its cavity towards the
substance of its walls, and these ulcerations, which are sometimes
covered with vegetations and fungosities, penetrate quite frequently in-
to the interior of the womb,  and present the  same symptoms nearly
as phagedenic (rongeant) cancer, and  noli me tangere on the face or
mouth.   Sometimes, on the contrary, the disease consists of an en-
cephaloid or  scirrhous mass, which is developed in the tissues of the
organ itself, near its free portion, or on any other point of its, tissue.
I have said above that  encephaloid masses, primitively developed at
the fundus of the uterus, sometimes protrude  through the neck, and
show themselves at  the upper part of the vagina,.under the form of
a polypus.

                      §  III.—Cauterization.

   Ulcerations, slight fungosities  and granulations alone, admit of the
employment  of caustics, comprising among these latter the zinc paste,
for tumors cannot in reality be removed except by extirpation, pro-
perly so  called.   Inasmuch as when the disease has yet extended but
slightly,  and  has but little  depth, we  are rarely certain that it is  a
cancer rather  than  any other  malady, alum, nitrate of silver, and
nitrate of mercury ought in  my opinion, in  many cases, to  be first
made use of.  When the affection is more advanced, and there is no
longer any doubt about its malignity, we may choose between muriate
of antimony, potash and chloride of zinc; as we may also, should we
be so inclined, make use of the actual cautery.  Nevertheless, as our
object is  not exclusively to  destroy the tissues, but also to change the
character of  the morbid surface; and as the nitrate acid of mercury
is of incontestable utility in a  great number of other alterations of the
same description, I can see no other  than advantages to arise from
its general adoption, and it is the remedy which I myself most fre-
quently employ.
  A.  After having placed the woman, who is to be supported on the
edge of the bed, and brought the  disease into view by means of the
speculum, the surgeon cleanses and dries the ulcer  by  successively
applying to it, by means of a long pair of forceps, small balls of lint
or small  pieces of sponge.  He immediately arranges between the
circumference of the neck and the inner surface of the  speculum,  a
small quantity of coarse lint,  to prevent the caustic from  extending
to the sound parts, and then applies to the bottom of  the ulcerous ex-
cavation,  a  crayon of caustic  stone  or nitrate of silver, either by
means of the  forceps or by a  port crayon of some length, or support-
ed in some other instrument.   If he should prefer the nitrate acid of
mercury, he saturates a roll of lint or  fine linen with it, and conducts
it to the parts in  the same  manner.  Before withdrawing the specu-
lum, injections of tepid water are to  be thrown up and repeated, to
prevent the cauterization from extending itself elsewhere than on the
diseased  part.   The woman is then immediately placed  in a general
bath, and kept  upon a  convalescent diet.  Should there be nothing
more than simple  excoriations,  and  slight ulcerations, it would  not
even be indispensable to wash the parts freely with water, and every
other precaution almost would become unnecessary.  The operation 
500
NEW ELEMENTS OF OPERATIVE  SURGERY.
 is renewed a greater or less number of times, according to the effect
 obtained from it, every four, six or eight days, and we do not finally
 dispense with it until the wound becomes red, vermilion colored, and
 granulated, and presents in fact, the aspect of ulcers which are in the
 course of cicatrization.
   B. It is also frequently useful to cauterize the entire interior of the
 neck.  For this purpose we introduce into it  the  pencil or  crayon,
 while the speculum keeps the lips open, and it was with the intention
 of performing  this process, that various caustic-holders, extremely
 useless in my opinion, have been devised.   Whether the cauterization
 may not appear to have been advisable, or has  not been attended with
 success, and where, moreover, we  are confident that the disease may
 be entirely removed, we must no longer hesitate, but proceed to ex-
 cision.

                        § IV.—Excision.

  In its natural state the free  portion of the neck of the womb has
 neither three, four, six nor eight lines in length, but in fact, sometimes
 one and  sometimes  another  of these dimensions, and without  being
 on that account diseased.   We may detach the vagina from the an-
 terior lip to the extent of more than  half an inch, without incurring
 the risk of  opening into the peritoneal cul de sac, which separates it
 from the bladder; only, as the bladder adheres quite intimately to
 its anterior surface, this  is the organ which may be then wounded
 by the instrument.   Posteriorly the  peritoneum  not only lines the
 corresponding surface of the uterus,  but  descends  down upon the
 vagina to form  the recto-genital cavity ; in such manner, that in this
 direction the bistoury would only  have to go to the depth  of a few
 lines to open into it.  It  must have  been  by inadvertence that M.
 Avenel (These, No. 80, Paris, 1828,) has said that there are but  eight
 lines of extent  in front,  and ten behind, between  the  apex of the
 lips of the neck and the interior of the abdominal serous membrane.
 As this  is a gross anatomical error,  I  am surprised that  it  should
 have been  again committed some years since,  (Gaz. Aled.,  1833
 p. 21, and 1834, p. 387,) and that  M.  Mury (These, No. 41,' Paris!
 1826,)  should  have ascribed the successes of M. Lisfranc to this
 discovery.
  A.  Operative Processes.—The mode of performing excision of the
 uterus did not suddenly reach the  degree of perfection to which we
 find it at the present day.
  I.  Osiander began by passing two ligatures,  by means of a curved
 needle, through the diseased  organ, which  latter  he depressed and
 secured in  this manner, so as not to exsect it until  after having
 brought it  down nearly to the vulva.   When  he could  not make it
 descend,  two fingers introduced into the rectum enabled him to ex-
 cise it :n  its place; but the invention of his hysterotome soon enabled
him to dispense with his ligature tractors.
  II. Dupuytren, and after him most other operators, have  substi-
tuted for the ligature of the surgeon of Gottingen, a very lono-  Mu-
seux forceps, the hooks of which are slightly curved, and by  means
of which we are enabled to embrace with facility the whole  of the 
CANCERS OF THE NECK OF THE UTERUS.
501
diseased portion.  As  this forceps readily tears the tissues, and as it
is frequently useful to apply a second one, M. Colombat has had one
made with four  branches.  Others have  proposed to introduce into
the womb, through the opening of the  neck,  an instrument which
might, in  opening in the middle of the  organ, be transformed  into
hooks, and allow of our  making strong  traction downwards.  The
most ingenious instrument of this kind is that of M. Guillon, (Soc. de
Alid. Prat., 1827, 1828, pp. 72, 73.)   Another, which is much more
complicated, has been proposed by M.  J. Hatin, and M. Recamier
has since  invented a third.
   III.  Speculum.—Osiander dispensed with the employment of the
speculum.  With us, on  the contrary, this instrument has almost al-
ways been made use of; also a number  of persons have endeavored
to improve it.  The one which M. Recamier first proposed was a
simple  cone of tin.  Dupuytren added  a handle to it, which gives
more facility in its application.  The ancients had one which is found
figured in the works  of Pare, Joubert, Manget, and Scultetus, and
which was composed of  two valves which could be widened or ap-
proximated at pleasure.  That of Madame Boivin, constructed upon
this principle, is formed of two halves of a cylinder, and has at its
large extremity a handle terminated by  two rings, like a pair of for-
ceps.   It  is introduced, shut up, in the vagina, and all that is neces-
sary is  to act upon the two halves of its handle in an opposite direc-
tion, in  order to open it in the manner of a scissors, and to dilate as
much as we desire the passage to be explored.  M. Lisfranc has had
one constructed which differs from the  preceding only in this, that
its apex,  which is somewhat flattened,  is more elongated, also its
diameter greater and its  handle destitute of any rings.   In order to
keep it opened at such  extent as we may desire, M. Guillon added to
it a stem or sort of slider, which, being displaced by the finger when
judged  necessary, immediately enables us to shut it up again.  The
same practitioner, with a view to avoid the pinching of the tissues, to
which we are more or  less exposed with the ordinary jointed specu-
lum, has added a third piece when we have adjusted the instrument
in  its place.   This piece is a plate which  is  glided from  the base to
the point of the two principal halves of the instrument, upon a groove
which is found upon each of them on the inner face of their free bor-
der.   Not content with having  a speculum with two branches, the
triple speculum, which  is also figured  in  the ancient works which I
have just  mentioned, has been revived.   But as it is the upper part
of the  vagina, particularly, which we have to dilate, MM  Bertze
and Colombat have contrived a speculum in the form of a cone, the
base of  which is found at the handle when  it  is shut up, and at the
other end, on the contrary, when it is open. . That of M. Bertze is
composed  of two tubes enclosed one  within the other.   The inner
one, which is divided into several rays in its upper  half, is disposed
in such  manner that its branches open by their own  proper  spring,
as  soon as we free them by drawing towards us  the  piece which
serves, so  to speak, as  their sheath.  Eight pieces  compose that of
M. Colombat, and form in their ensemble a hollow cone, the point of
which  is opened or contracted to a greater  or  less degree when the
instrument is  in its place, by means of  quick  screws placed at the 
502
NEW ELEMENTS  OF OPERATIVE SURGERY.
 two extremities of one of the great diameters of its base.   When
 open this instrument represents'a sort of grillage, the  same as is seen
 in the speculum of Duges or M.  Mayor, and which enables us to see
 at the same time both the neck of the uterus and  the interior of the
 vagina.   Of all these varieties of speculum, that which Mad. Boivin
 suggested, (Bull, de  la  Fac  de Med., t. VII., p. 349,)  but  which
 has  undergone remarkable improvements since, appears in my judg-
 ment to be the best.  The only  inconvenience which I find in it, is
 that of allowing  the mucous  membrane of the vagina  to become
 caught  between its borders, and of exposing to the risk of pinching
 it when it is shut up.  But  this  inconvenience, which the proposed
 modifications have as yet but very imperfectly remedied, exists to a
 much greater degree in the speculum  with three branches  of M.
 Hatin, in  that of M. Colombat, and even in that of M. Bertze, all of
 which, moreover, may wound  the organs  by their point and are far
 from reflecting the light with as much advantage.  Under this last
 point of view, the  original  speculum or simple cylinder  is still the
 most commodious, without even excepting the cribriform or perforated
 speculum  contrived by  M. Ricque.  At the present day we have,
 moreover, the speculum of M. Galenzowski, (Journ. des Prog., t. V.,
 p. 237.) which  differs from  the ordinary speculum only in having a
 cylinder or cap of ebony, which is adjusted  upon it in order to intro-
 duce it, and  which speculum  M. Melier (Mem. de VAcad. Roy. de
 Chir.,) considers  as  the  best; also we have the speculum of  Lair,
 (Arch. Gen. de  Med., t. XVII., p. 141,)  that of M.  Jobert,  the specu-
 lum of M. Ricord, that of M. Sirhenry, those of M. P. Dubois, (Ibid
 t. XXII., p. 278,) M. Moreau, M. Clairat, and M. Charriere, without
 counting the vibratory speculum  of M. Duparcque.
  IV. As to  the cutting instrument, properly  so called,  many de-
 scriptions  of these also have  been made use of.   Dupuytren, for ex-
 ample, frequently made use  of a  sort of scoop or trowel,  somewhat
 concave, and having  a  cutting  edge only on its  upper extremity,
 which is convex, and of a semilunar form.   By means of  a circular
 movement this blade will  divide the heck at the  bottom of the specu-
 lum ; and  it may even be made,  if necessary, to penetrate into the
 womb, so  as to hollow out this  organ in  the  manner of a cone.  M.
 Hatin has applied  to  the  stem  of his principal instrument, a forceps
 terminated by two cutting extremities, like the spoon-shaped forceps
 of F. ab Aquapendente, or that of Lobstein.  The erigne forceps of
 M. Colombat has  combined with it a stem, upon  the extremity of
 which is situated  a small blade placed  transversely,  which may be
 elevated or depressed by means of a particular apparatus, and which
 when turned upon  this stem, smoothly cuts the entire  circumference
 of the neck above the prongs  of the erigne.   The hysterotome or
 secator of Mi Arrhonson, (Ibid., t. XXII.,  p. 278,) would be at the same
 time more simple and more convenient, if instruments of this kind could
 be substituted for the bistoury in an operation of this description
  V.  Even the  ligature, as mentioned by Lazzari, and which mijrht
in fact be applied, has also  had  its advocates.   M  Mayor thinks
and not apparently without reason,  that by introducing above the
disease a silk ligature with his  conducting instruments, the neck of 
CANCERS OF  THE NECK  OF THE UTERUS.
503
the womb might afterwards be readily strangulated by means of his
chaplet constrictor.
  VI.  Finally, all these modifications of the operation maybe classed
under two methods, one  which consists in making the neck  descend
as low as possible before excising it, and the other, which gives the
preference to excising it in its  natural position.  This last at first
sight seems much more advantageous than the  other in this  respect,
that it protects us from all kinds of traction or laceration.  Never-
theless, it is less convenient, in the first place, because it does not al-
low us to ascertain with  as much precision the condition of the parts,
nor to penetrate as far  or  with as  much  security in  the direction
towards the womb, and in the last  place, because it is from this
circumstance  evidently  more difficult of application.  It does not
therefore deserve the preference, except in those cases in which the
uterus is too firmly fixed to enable us by the most judiciously direct-
ed  tractions to make it descend  into the lower strait.  In the  first,
there can be no longer any question about the threads of Osiander,
since we have known how to modify in a proper manner  the erigne
forceps.   The speculum  also, of whatever description it may be, ap-
pears to me to be much more embarrassing than useful.  The hooks
of the  instrument, guided by the fingers of the left hand, may always
be  placed around the neck without much difficulty.   If it  should be-
come  advisable to increase their number, in order to prevent any
laceration, it is better to  imitate Dupuytren, and place a second Mu-
seux forceps above or upon the opposite side of that of the first.  As
the straight bistoury wrapped in a band may be conducted  to a suf-
ficiently great depth in the  vagina, it has appeared to me to  be as
useful  as any other instrument.  I have  no necessity of remarking,
that the tractor instruments which open themselves in the interior of
the parts, would in  most  cases be dangerous, and that they ought to
be  absolutely rejected.   When we are obliged  to excise the  neck of
the womb without  displacing it, it is difficult to dispense with the
employment of  the speculum. As  we require as much space and
freedom as possible, the jointed speculum is then the only one which
could fulfil the intentions of the surgeon.  It would be in such cases
also that we might, if necessary, make use of  the scissors that are
slightly curved, the cutting ring, the scoop of Dupuytren,  or the bis-
toury which is concave on one of its flat sides near its extremity.
  VII.  Operative Process.—The woman is placed  in the  same way
as for cauterization.   One assistant supports her head and arms, two
others  attend to her lower limbs, and a fourth hands the instruments
as they may be required.
  a. Introduction of the  Speculum.—The surgeon placed in  front of
the vulva, begins with the introduction of the speculum, if he has de-
cided upon using this  instrument.  After having besmeared it with
cerate, he glides it gently into the axis of the pelvis, resting it chiefly
upon the posterior commissure of the pudendum at first, directs it in
this manner to the seat of the disease, and inclines it more or less in
front, posteriorly or to one  side, according as the neck presents it-
self more or  less  perfectly at its extremity; and  on  the contrary
opens it if it is jointed, in such manner as to dilate the vagina com-
pletely, and to expose the whole extent of the mischief.   Upon the 
504
NEW ELEMENTS OF OPERATIVE SURGERY.
 supposition that he wishes to leave it in its place to apply the forceps,
 he immediately causes it to be held by an assistant until he has accu-
 rately adjusted them.   He then withdraws it.  and  it is at this  mo-
 ment particularly  that.the jointed speculum  possesses an advantage,
 by allowing the forceps to be readily disengaged from it above.
   b. If the operator dispenses with the speculum, two fingers of his
 left hand are first introduced  into  the  bottom  of the vagina, where
 they are  to remain, after having recognized the form  and extent of
 the cancer.  He then conducts the forceps, shut up, upon their  pal-
 mar surface, opens it on reaching the tumor, and applies it as high
 up as possible,  in such manner that its hooks may be implanted on a
 sound  portion of the neck.  By means of this forceps, which should
 be inserted by pushing rather than by drawing upon it, he endeavors
 to  make  the organ descend  into the vulva.  In place of effecting
 these tractions  with the two hands, it is better to employ the right
 hand only, acting all the while in the direction of the axes of the  pel-
 vis, and to make use of the fingers of the left hand to protect, without
 ever letting go their hold  upon the hooks of the  instrument,   If he
 perceives that  these hooks have lost  their hold, or that  the parts
 embraced by them have a tendency to become  lacerated, he  imme-
 diately applies  a second forceps on  the opposite part of the diameter
 of the neck, after having charged the assistant to hold the first.
   c. When the parts are  brought out he cautiously separates  the
 sides of the vulva; gives the tractor instrument or instruments to
 one of the assistants, and having seized the bistoury which has been
 prepared applies it first on the right side and always above the dis-
 ease, brings it in  front and then to the left, or  might also make  the
 section of the parts from behind forwards and from left to right.   If
 the disease should not  appear  to be accurately defined, he  should
 attend to the adhesions of the vagina and destroy them, little by little,
 in such manner as  to remove not only the os tinea) but also the upper
 portion of the neck, and  to  hollow out the lower part of the  womb
 itself in the manner of a cone, upon the supposition that this  should
 be deemed necessary.
  d. As  soon as the excision is completed, the  fundus of the organ
 mounts upwards and resumes its natural position.  If anv remnants
or tubercles of  the cancer have been left  behind, we must re-intro-
duce the speculum, grasp them with the forceps, and immediately  ex-
cise them, or we may destroy them by means of caustics
  VIII.  Subsequent Treatment.—When there is no hemorrhage, there
is no necessity of any dressing.   We  confine ourselves  durin^  the
first days to injections of tepid or cold water.  Nevertheless I could
 see no inconvenience m gliding in upon  the bleeding surface a fine

with small balls of lint.   If the blood flowed in too grtat abundance,
this chemise would give a great degree of facility to the tamponing
 and would expose  to no dangers which could  not be immediately
 remedied.
  The  dangers of excision of the  uterus arise from •  i  w
 rhage, which M. Pauly (Malad.de V Uterus, pp. 446  447 448 4?i~
453,454) has seen take place in seven instances out o'f thirteen  'case*'
 and result in death in  three women at the end of a few hours;  2.' 
              CANCERS OF THE NECK OF  THE UTERUS.          505

Peritonitis,  which also frequently occurs;  3.  Phlebitis, which has
already been observed in several instances ; 4. Purulent inflamma-
tions in the  pelvis ;  5. Perforation of the peritoneum, rectum or blad-
der ; 6. A return of the disease.
   IX.  Appreciation.—Up to the  present  time I have performed ex-
cision of the neck in but eight instances, and  for that purpose have
required nothing more than Museux's  forceps, a knife, curved scis-
sors, and a straight bistoury.   In the first  woman the whole of the
neck was diseased,  and the operation was prompt, easy and attended
with but  little pain.  A certain  quantity of blood was  discharged,
whicn was  checked by the use of simple means.   She died, however,
on the third day, but we found, on opening the  body, neither perito-
nitis nor other appreciable lesion.   The rest of the uterus was sound,
but there was a small cerebriform mass upon the right of and behind
the vagina.   An  opening also, of two lines in extent, was found on
this wall of the vulvo-uterine passage, and communicated with the
recto-genital cavity.  Was this produced by the operation, or did it
depend on the manipulations used in the autopsy ?  This is what we
could not ascertain, but we clearly satisfied ourselves that no matter
had been effused through this opening.   In the second case, finding
some difficulty in bringing the cancer down, I introduced  without any
great degree of difficulty, above its situation and at two inches depth
in the vagina, the straight bistoury wrapped in a bandage, and gui-
ding it upon the palmar surface of the fingers of my left hand, in this
manner terminated the operation.   This patient, who at first appeared
to be  doing well, died  at the expiration of six weeks.  She had a
number of cerebriform masses in the  lumbar region, and also in the
substance of the broad ligament on the right side.   I proceeded in
the same manner with the third patient, about the close  of the year
1832, at the  hospital of La  Pitie.  The top of  the neck formed an
encephaloid  mass of a mushroom appearance,  which was as large
as the half  of the fist.  No accident interrupted the cure, and the
woman, who was perfectly restored, came to  see me a year after to
know if she  could resume her conjugal  duties without any danger.
In the fourth, fifth, sixth and seventh cases,  there was a return of the
disease.  The eighth woman, whom I operated upon at  La Charite,
in 1836, was cured without  any accident,  but it is not  certain that
the tumor was a cancer.   None of them had any serious  hemor-
rhage.
  A. A patient operated upon  by M. Blandin, died of uterine phle-
bitis.  MM. Rust and Graefe at  Berlin,  and  M. Roux and Dupuy-
tren, have also seen death take place in some instances from  the im-
mediate consequences of the operation.   Excision of the neck of the
uterus, therefore,  though easy and in many cases unattended with
serious consequences, is  nevertheless in  some" instances dangerous
and speedily fatal.  From the considerations, moreover, which have
been laid down in the beginning of this article, it would seem that it
can but rarely be  successful.  It has however been greatly extolled,
and Osiander has  performed  it 28 times,  Dupuytren  from 15 to 20,
and M.  Lisfranc from 40 to 50.   Women who have been submitted
to it, have  been enabled to become pregnant, and have been deliv-
ered once  or oftener without accident.  Dupuytren even  relates
  vol. in.                      64 
506
NEW ELEMENTS OF OPERATIVE  SURGERY.
  cases in which  he  was obliged to operate a second  time, in conse-
  quence of a return of the disease, but which were nevertheless cured.
  Finally, it is asserted that in the great majority of cases the cure has
  been radical.
    B. Without examining in this place whether, since excision of the
  neck of the uterus has been  employed  in  practice, it has not been
  quite frequently had recourse to when there was no cancer as  some
  persons have maintained, I will  confine myself to remarking that Du-
  puytren, who, so to  speak, introduced it into France, ultimately re-
 jected it;  that M. Lisfranc also appears to  perform  it  less frequently
 than formerly; and that Osiander himself, according  to  M. Heisse,
 no longer made use of  it for some time before his  death.  The two
 examples related also by M. Stoltz, are  but little calculated to pre-
 sent a very favorable idea of it.   Of the six patients operated  upon
 by M.  Cazenave, (Bull, de VAcad. Roy de Alid., t. I., p. 930,) four
 died, one only  was cured, while the sixth was in good health at the
 moment at which he wrote.   Moreover, a report which was first in-
 distinctly circulated on this subject, has  ultimately made  its appear-
 ance in scientific works.  Thus M. Krimer,  (Revue Med., 1835, t. III.,
 p. 254,) asserts that excision of the neck  of the uterus has never suc-
 ceeded when the disease was an actual cancer;  that at  Paris every
 body is under a delusion on this subject;  that a lady who was given
 out as cured to the learned societies and journals of  medicine, never
 has been cured, while M. Pauly, (Mai. de V Uterus, 1836, in 8vo. of
 536 pages,) sustained by MM. Carron du Villard, Treille, Duparcque,
 &c, holds precisely the same language !   M.  Lisfranc, who is espe-
 cially implicated  in this matter, and who states that he has succeeded
 in 84 operatians  out of 99, (Gaz. Mid., 1834, p. 389,)  must, if his
 former assistants are  to be believed, have recklessly (effrontement)
 abused the public, the physicians, and the academies, in citing  as cured
 a nimber of  women who died;  in  exaggerating  to twice  their
 amount the  number of his  operations; in amputating  as  cancerous
 the neck of the womb when it was scarcely diseased;  and  in being
 guilty, we must confess  it, of actual atrocities, (atrocites,) if the ac-
 cusations against him are true.   The facts enumerated  by M. Pauly
 are moreover so precise, so numerous, and apparentlv so conclusive
 that the feelings are outraged by them, and that it must ever appear
 extraordinary  that  M.  Lisfranc has never  disavowed them.   Per-
 ceiving that M. Pauly is deceived in relation to what concerns my-
 self, I am on my own part disposed to think  that he  errs also in re-
 gard to his former preceptor, but the honor of M. Lisfranc  and his
 regard to truth, (sa moralite,) imperiously demand an explanation on
 his part of so grave a question.
  C.  Reducing the operations of M. Lisfranc  to 47 for example in
 place of  99, M. Pauly finds at least thirty failures.   In a list of'23
 successful cases, deposited at the Institute, and which this  physician-
 has examined, he  finds that three were repetitions, 9  supposed cases
2 cases of excoriations that were merely cauterized,  2  excisions of
 small polypi, 2 cases of return of the disease, and three or four only
of actual success!  Out of  14 operations  which he himself was wit-
ness to in the practice of M. Lisfranc, from January 1st  1833 t"
January  1st, 1836, M. Pauly affirms that one only probably was Vol- 
EXTIRPATION OF THE  UTERUS.
507
lowed with success !   It must be confessed that if such assertions are
false, M. Pauly is highly culpable, he especially the favorite (partic-
ulier) pupil  and confidential secretary of M. Lisfranc!   But also,
if they  are  true, what a  disgrace to the profession, and by what
name should we characterize the author of such crimes, (mefaits ?)
  D. In fine, I would not recommend that  the  neck of the uterus
should be excised for simple ulcerations, if it  is  not in a cancerous
state.  I am aware that in cases of cancer the disease may repuUu-
late ; that when it is not possible to remove the whole it had better
not  be  meddled with;  that  errors  have  been committed  under
this double point of view; that men with a  usurped  reputation and
trampling under their feet the laws of humanity, have dared to jus-
tify  in some instances the acts reprobated  by M. Pauly; but I do
not grant that this operation in itself is as brutal as has been asserted,
nor that when it is performed  under  the conditions indicated above,
it  ought to be  any  more proscribed than  amputation  of cancer-
ous tumors of the breast, testicle, or in fact any other region ; it is
the abuse of the operation, and not its use which we ought to con-
demn.

           Article  X.—Extirpation of the  Uterus.

  The removal of the uterus was for so long a time deemed impossi-
ble, that even  in our days it is still doubted if the operation has ever
in reality been  performed.  A very different opinion however has
been advanced by a number of authors at almost every epoch.  To
prove that this organ  is one of little importance  in woman, Soranus
(Peyrilhe, Hist, de la Med., p. 282) affirms  that  it may be removed
without causing death, as Themison, he says, demonstrates in his
writings, and  he even goes so far as to lay down the operation as a
precept; for he recommends, without any reserve, that the prolapsed
uterus should be extirpated if it is in  a putrified state, and positively
asserts  that it  has been, in  some  instances, excised  entire with
success.   To understand ourselves on this subject it is necessary that
we should not confound extirpation of the uterus  in a prolapsed state
with extirpation of a cancerous uterus which has not  been displaced.

                     § I.—Prolapsed Uterus.

  In the additions  of Bauhin to the works of Rousset, we find nine-
teen cases which  in part justify the  boldness of the physician  of
Ephesus, and Schenck relates  a still  greater number, but which  all
have reference to  prolapsus of the womb.   Nevertheless, inasmuch
as  among the  cases which are described, there is  a considerable
number of them which are deficient in the necessary proofs and
details,  they  have  possibly  been  rejected  without examination.
Rousset exhibits so much want of good faith  in his work, and Bauhin
and Schenck appear to be so credulous, that we are naturally induced
to distrust their testimony.  How can we believe that the uterus was
removed in the woman mentioned by Plempius, but who neverthe-
less  afterwards  became pregnant; or how  believe in the case  of
another who, according to Plater, retained her venereal desires and 
508
NEW ELEMENTS  OF OPERATIVE SURGERY.
 continued  to have  her  catamenia?  Or  in  a  third case  cited by
 Schenck. from Carpus, or in that mentioned by Morgagni, from Wide-
 mann. and in both of  whom  were presented  the same phenomena?
 Will Vieussens, who gives the details of an autopsy in a woman
 from whom  he  removed the uterus  fifteen  years  before, produce
 greater conviction in the mind  because we find him asserting that a
 remnant of the organ had been left at the bottom of the pelvis ?  The
 case  of a certain Pierrette Boucher, who was operated upon  three
 years before, and whom Rousset disinterred three  days after her
 death and opened in  the presence of a physician and midwife, whom
 he does  not  name, could it be any other than a tale  invented for
 pleasantrv  ?  Nevertheless it is an  incontestable fact at the present
 dav. that "the ablation of the prolapsed uterus has been performed in a
 number of instances, and that in certain cases the women have sur-
 vived.  Without speaking of the instances cited by Moschion, Aven-
 zoar, Rhazes, Mercurialis, Woega,  Fernel, and Benivenius, (Bonet,
 Corps de Med., t. IV., p.  599,) &c, we find one in Pare which can-
 not admit of a doubt.  The operation took place in  1575, on King's
 day, and the woman did not die  until three months after, and of
 another disease.  Upon opening the body Pare was enabled to prove
 the absence of the uterus, and he remarked as a beautiful arrangement,
 that  nature had done nothing more than  construct, in  place of the
 extirpated organ, a simple induration at the bottom of the pelvis.  In
 this point of view we may classify the facts that are known in  rela-
 tion  to the extirpation  of the displaced uterus, under two principal
 heads; in one there has been  a simple prolapsus of the  organ, while
 the others relate to its inversion.
  A.  Prolapsus.—Among the first are  to be reckoned, as I consider,
 the case  of H. Saxonia, in which  it is  perceived  that  a servant
 woman of Venice tore out herself  her prolapsed uterus;  those of
 Paul of Leipsick, Cohauzen, Tencel, Goulard and Blazius; and those
 even that Laumonier in 1784,  Clark, Vanheer and A. Hunter in 1797,
 and that M. Hosack,  and  M. Galot of Provence, in 1809, have since
 published.  If all these  facts could not be received as authentic, or if
 it should seem evident that Laumonier and  Bardol, among others,
 have only removed a polypus in place of the entire womb, the same
 conclusion no longer  applies to M. Galot, (Bull, de la Fac. 5th year,
 p.  15,) who transmitted his specimen to the Faculty of Medicine at
 Paris, nor to M. Marschall of  Strasbourg who, upon the death of the
 woman ten years after, had  an opportunity  of verifying  upon the
 dead  body the absence of the uterus.  M. Langenbeck, moreover,
 (Bull, de Fer., t.  XVII.,  p. 72.) performed this operation with su<>
 cess in 1813.   Nor can the case of Fodere, published  in  1825,orthat
 of MM. Recamier and Marjolin, (Revue Med., t. IV., p. 392; Arch. Gen.
 de Med., t. X., p. 88,) that of Delpech and that of M. Bellini, (Mem. sur
 VAmput.  de V Uterus. Broch.,  1823,) admit of  the least doubt on  this
 subject.  The prolapsed uterus, therefore, has been in several instan-
 ces detached from the body without  causing the death of the woman.
  B. Inversion.—In the second class, which also comprises doubtful
facts and such as have a greater or less degree of authenticity, is to
 be included the case of Ulm, who states that a midwife,  after having
inverted the uterus by drawing upon the umbilical cord, removed the 
EXTIRPATION OF THE UTERUS.
509
organ with one cut of the razor; the other fact also, almost in every
respect similar, except that the woman got well, which is related, by
Bernard; a third of the same character, mentioned by Vrisberg ; that
by Viardel; a fifth published by Caille and obtained in the Bas-Poitou;
that published by Anselin of Amiens, and in which he himself removed
the inverted organ; in a word, to this class belong the cases of R. Bax-
ter, Miillaer, Jean Miiller and Sorbait; those related by Figuet of Ly-
ons, and Faivre of Vesoul; and that in which it is asserted that Desault
excised a portion of the  fundus of the inverted uterus, while remov-
ing a polypus.   Without enumerating the cases of Gattinaria, Beran-
ger de Carpi and Fonteyn, quoted by M. Dezeimeris, we must add
also to this list those taken from the practice of MM. Chas.  Johnson,
(1822,) Newnham, (Journ.  Univ. des  Sc Med., September, 1818,)
Windsor, (1809,) Rheineck,  Davis, Chevalier, Weber, Gooch, Cor-
deiro, &c.
   I. Partial Inversion.—There is a  kind of inversion which has not
sufficiently attracted the  attention of surgeons ; it is that which takes
place partially only.  We then perceive in the vagina a firm elastic
pyriform tumor, which readily bleeds and is terminated above by a
pedicle of  an inch or two in  diameter, and which  conveys the idea
of a fibrous polypus, and is ordinarily accompanied with intermittent
hemorrhage, a sense of drawing down in the loins and groins, and by
a feeling of weight upon the fundament. It is distinguished  from
polypus by its velvety aspect, its reddish or violet-like color, its neck,
which the orifice of the attenuated uterus encircles in the manner of
a ring, and by the void which the fingers introduced into the rectum
or the hand  applied over the  hypogastrium, while other fingers are
introduced into the upper part of the vagina, find to  exist in the place
which should be  occupied by the  womb.  This malady,  from its
coming on  in some instances  without the woman being conscious of
it, or without any previous accident, cannot be recognized until after
the expiration of several months or even of a year.   It is not always
then easy to distinguish it from a polypus, notwithstanding  the signs
which I have just given.   The proof of this I saw in 1836,  in a lady
24 years of age.   Since  her delivery, nearly three  years before, she
had  been constantly annoyed by losses of blood, which were some-
times small  in quantity and at other times abundant.   Some of the
surgeons of the country had at first supposed it to be an inversion of
the uterus, but the others finally came to a decision that it was a poly-
pus.   This lady,  having come  to Paris, consulted several practi-
tioners, who all adopted  this  last opinion.  Its  extirpation was de-
cided upon, when I in my turn was  requested to see  her.   Having
entertained some  doubts, I repeated the examination of the tumor,
which was  of the size of  an egg, and had the density, elasticity and
form of a fibrous body descended into the vagina.   Having placed
my hand on the hypogastrium, and the forefinger as high up as possi-
ble in the  rectum, while  with two fingers of the other hand 1 em-
braced the neck  of the tumor, I was enabled to satisfy myself that
there was nothing in the usual place occupied by the womb, and felt
authorized in asserting that the case in question was one of inversion
of the uterus, instead of  one  of polypus.  The  event demonstrated,
as will be related  farther on, that this diagnosis was  correct.  In a 
510
NEW ELEMENTS OF OPERATIVE  SURGERY.
 case preciselv similar,  which A. Petit (Soc. de Sante de Lyon, 1798,
 p. 103) and the  surgeons of the Hospital of Lyons had supposed to
 be a polypus, Rev placed on the neck of the tumor a ligature which
 caused such acute pain  that he did not dare to continue the operation.
 The woman died a few days after, and an autopsy of the dead body
 showed that the case was  one of inverted  uterus.   The embarrass-
 ment is sometimes so much the greater from the fact that polypi of
 the uterus may dilate and gradually attenuate the neck  of this organ
 by dragging down the fundus and inverting the entire body of this
 organ.  I have already related an example of this kind, verified at the
 opening of  the dead body, in  treating of  polypi, and I met another
 in 1839, in a woman who also died of peritonitis.  If no variety of
 polypi exhibited a  velvety appearance, or emitted from its surface a
 sanguineous exhalation, in the same manner as does the proper tissue
 of the womb,  we  might perhaps obtain  more  authentic signs  by
 means of the speculum  than by the touch.   A tumor however which
 is velvety,  of a reddish color, bleeding,  destitute of  prominences,
 pyriform, surrounded above by a circular groove like  a cul de  sac,
 sensitive and painful upon  pressure,  while at the same  time there is
 found to be a void  in the place that the uterus occupies, must be con-
 sidered to be an inversion of the uterus and not a polypus.   Incom-
 plete inversion involves accidents of a more serious character than a
 prolapsus or a descent of the womb, properly so called.  The repeat-
 ed hemorrhages which it   occasions gradually exhaust the  woman
 and ultimately terminate in death.   The patient cannot get up or
take  the slightest exercise without being threatened with syncope, or
without feeling a sense  of weight and traction, which soon give them
 cause for alarm.  A lady whom I frequently saw with M. Marjolin,
in 1836, was in this condition after four years of suffering; this lady,
who  was pale, anoemic and already attacked  with  swelling of the
feet,  though  in other respects in tolerable health, could not rise from
her bed, and was constantly troubled with a sanguineous or leucor-
rheal  discharge.  Having  returned  to  her  province without having
been benefitted  by our treatment, she continued there in  the same
state, and I have heard  nothing further from her since the year 1837.
 Should the accidents which partial inversion  produces be of trivial
character, or allow  of the woman  taking  some exercise,  and  of
attending to some of her occupations, we ought to confine ourselves
to the palliative treatment, that is to say, to a mild diet and astringent
injections,  or even the use of a  saucer or gimlet-shaped  pessary.
 Under opposite  conditions  there are grounds  for attempting a radi-
 cal cure.
  a.  Reduction.—The  diagnosis  having  been once  clearly ascer-
tained, it would appear that the first  indication to fulfil should be to
reduce the tumor  and  return  the organs  to their natural  position.
Experience, unfortunately,  has too frequently proved, what  reason-
ing moreover would point  out, that this reduction is almost impossi-
ble, and that it would not always be prudent to  attempt it.  In the
first hours or days which succeed to a uterine inversion, we might hope
for success in attempting reduction, because then the inverted portion
is still supple, and  the neck through  which it has  protruded is not
contracted and indurated to such degree as absolutely to prevent its 
EXTIRPATION OF THE UTERUS.
511
reascension.   At a subsequent period, and after several months or
years have passed, we can no longer hope for such  a  condition of
things.  Now the tissue of the womb has adapted itself to its new
form and its new position.  Its mucous surface has assumed the di-
mensions of its former external surface, while this latter has become
contracted within in such manner as no longer to represent anything
more than  a cavity of very small extent.  The neck contracted upon
itself, has become too narrow to admit of the return of the body and
fundus of the uterus, which are below it.
   b. Removal of the tumor.—Consequently, in order  to cure  a wo-
man at this period of her disease, we have no other resource left than
ablation or strangulation of the tumor; this operation, therefore, then
becomes a modification of that of extirpation of the uterus.  Whether
we make use of the ligature, or have recourse to excision, the opera-
tion has always appeared to be of so dangerous a character, that but
few surgeons  have had the courage to undertake it.  If we strangu-
late the tumor in the  same manner as a polypus, by  one of the pro-
cesses pointed out above, we have to make so powerful a constric-
tion, and one that is protracted to so long a period  of time, that it is
soon  succeeded by excruciating  pains,  nervous  symptoms, or even
convulsions, and sometimes by  a fatal  peritonitis.  In cases of ex-
cision, the hemorrhage may be of a  frightful character; as we open
the peritoneum, peritonitis is still more to be apprehended than in the
preceding case; the blood retained in the vagina may pass  into the
abdomen, white the intestines may protrude in the direction of the
.vagina.   Unfortunate cases,  taken  from the practice of  several
celebrated  surgeons, may be adduced in support of these assertions.
We should go too far,  however, in supposing these operations always
fatal.  The young lady  of Chateauroux,  whom I have mentioned
above, is a proof of this.  I grasped  the tumor with  an erigne for-
ceps, which I placed in the charge  of M. Rivaille, the family phy-
sician of the patient, and who officiated as my assistant.  Two fin-
gers of the left hand introduced in  advance, served me as a guide
for a long curved knffe, with which  I divided layer by  layer the en-
tire neck of the organ, in such manner as to leave  nothing of it be-
hind but the part which was embraced by the neck of the uterus.
The finger being introduced through the wound, entered freely into
the peritoneal  cavity,  and could distinctly feel the intestines.  It was
easily  perceived immediately afterwards, that  the  totality  of the
body of the uterus had  been  removed, and the specimen which I
have preserved for a long time, has left no doubt on this point in the
minds  of those who have examined it.  The hemorrhage was slight,
but excruciating pains, cramps, and an extreme degree of agitation
with syncopes, which  soon came on, continued with so much inten-
sity during the space  of  three days, that we had entirely given up
our patient in  despair.   Opiate preparations internally and exter-
nally, mercurial unctions upon the lower  part of the belly,  Seltzer
water, and  the potion  of Riverus, administered for the nausea, ulti-
mately succeeded in calming all these accidents, so that in less than
a month the cure was complete, and has since remained permanent,
though the  operation took place in 1836, (Thouret, These, No. 345,
Paris,  1836, p. 20.)   The only circumstance which  has sometimes 
512
NEW ELEMENTS OF OPERATIVE SURGERY.
 still caused anxiety in the mind of this lady, who has never known
 what was removed from her, is that  of no longer having her cata-
 menia !  A case almost in every respect similar, belongs  to M. Las-
 serre, (Arch. Gen. de Med., 2d ser., t. VIII., p. 395.)   Operated
 upon eighteen  months after delivery, the  ligature was first placed
 on the neck of the tumor, which resulted  in producing excessively
 acute  pains.  The surgeon then proceeded  to excision; new acci-
 dents supervened, but  the woman ultimately recovered.  A similar
 operation performed about the same  time  in England, by M. Blox-
 ham, (Gaz.  Med., 1837, p. 122,) caused the  same agonizing pains, but
 ultimately resulted also in a cure. It was the graduated ligature, and
 not excision, that this surgeon made use of.  A. Petit (Soc. de Sant.
 de  Lyon, 1798, p. 209) affirms, however,  that an experienced sur-
 geon, mistaking an inversion of the uterus for a  polypus, strangulated
 and successfully effected the separation of the tumor, without occa-
 sioning any severe accidents.  If it should seem surprising that so
 many  accidents supervene in consequence  of the excision  of an
 everted uterus, while the extirpation of the  uterus, in its natural posi-
 tion, or entirely prolapsed from the pelvis,  does not  always produce
 the same results, I would  remark that  in partial inversion,  the instru-
 ments and  ligature are necessarily applied  directly  upon  the  tissue
 of the uterus itself, and that in cases of this kind, the women who
 have been delivered only  some months or some years before, are of
 necessity still young.  Those two cases which I have met  with, were
 of the ages of 24 and 26 years.  As to the choice to be made be-
 tween extirpation and the ligature, this must necessarily be embarrass-
 ing in the present state  of our knowledge upon this subject.  Stran-
gulation  appears to  be constantly followed with excruciating pain,
 but the hemorrhage which may succeed to simple excision, has also
 something in it of a frightful character.  It is true however that I did
 not find this take place in  the patient of M.  Rivaille, and that in fact
 we cannot in this region divide any vessels of very considerable size.
 This is a question  therefore which in  all its relations should be re-
 examined and re-investigated.  The manual of*the operation, more-
over, whatever may be the process we adopt, is the same  as for po-
lypi, or the extirpation, properly so called, of the displaced uterus.
  II. Complete  Inversion  and  Protrusion of the  Uterus.—If all
attempts  at reduction have failed, and the disease appears to threaten
the life of the  patient, we may have  recourse  to  the  ablation of a
uterus which has descended  outside of the  vulva ; but we must  not
forget that the pure and simple prolapsus of the womb is rarely fatal;
that it may constitute nothing more than an infirmity ;  that it has in
several instances been susceptible of pregnancy, as is proved by the
case related by Marigues of Versailles and that of M. Chevreul;
that in most cases the general health scarcely suffers; and  that there
should be a degenerescence and morbid condition, which are in them-
selves dangerous, to compel the surgeon to  adopt a decision of this
kind.   Its inversion after the expulsion of the foetus is in general  so
easily remedied, that it  cannot, except  in rare cases, require the in-
 terposition  of so dangerous an  operation.   Nevertheless,  should the
 woman have  been badly treated, or  should brutal or ill-directed
manipulations have brought about a state of gangrene or disorganiza 
EXTIRPATION OF THE  UTERUS.
513
tion in  the  uterus, so  that there could no longer be any possible
hope of replacing  or  preserving it, its ablation  would  be a final
resource, which we should be wrong  to deprive ourselves of; not
losing sight, however, of the fact,  that the women mentioned  by
Blasius, F. de Hilden and Ulmus, as having been operated upon by
midwrives, died in consequence thereof; that  the same result took
place in the patient of M. Wolf, (Journ. de Grq&fe et Walther, vol.
VII., p. 482;) that the  patient of MM. Recamier and Marjolin survi-
ved only two months; that  an unfortunate woman  received  in La
Charite, in the month of July, 1824, and in whom the inverted  womb
had been by mistake constricted by a ligature eight days before, also
succumbed  a few weeks  subsequently; and finally, that if the two
cases related by M. de  La Barre and Baudelocque, in which it is seen
that the uterine inversion disappeared spontaneously at the expiration
of several weeks in the first, and after a continuance of more than
seven years in the second, should be  deemed  authentic, amputation
in such cases can be but rarely indispensable.   The woman who, ac-
cording to M. Swett, (American Journ. Med. Sc—Gaz. Med., 1834,
p. 665,) recovered, notwithstanding  she had lost in this  manner the
entire uterine system, bladder, rectum and perineum, would have
obviously been less fortunate, if in  place  of being born  in America*
she had lived among us !   The persons who have performed ablation
of the displaced uterus,  through ignorance or rashness, have conducted
themselves in such manner that their process does not merit any con-
sideration.   Nor can we in fact any longer treat of tearing  out or ex-
cising the womb with a kitchen-knife or razor, without any preliminary
precautions, nor of hot ashes, or other caustics used by certain women
and charlatans, and by some ancient authors.   The rational methods,
from which  we are now permitted to make a selection, are, strangu-
lation with or without immediate excision, pure  and  simple amputa-
tion, and extirpation with dissection of the peritoneum.
  a. The ligature is extremely easy, and so much  the more so as we
have under our eyes the pedicle, around which it is thought advisable
to apply  it.   But this  pedicle possesses  a certain volume, and the
pains caused by its constriction have in more than one instance been
so acute, that the  life of the patient appeared to be in imminent dan-
ger from it.  In the patient of M.  Marschall, among others, it soon
became necessary to divide the thread, and the excision, which was
decided upon on the spot, was followed by complete success.   This
ligature,  moreover, exposes  to  the  danger of including in its con-
striction  either  the  urethra,  as  was seen by  Ruysch;  or a  noose
of intestine, as happened to the charlatan mentioned by Klein,  or the
other spoken of by Reyneck; or the bladder, &c.  With a view of
effecting  the excision more promptly, and of causing less intense pain,
M. Windsor, as Faivre had done before him, perforated  the root of
the tumor with a double thread, in order to strangulate its two  halves
separately.   The  cases,  however,  of Newnham, Clarck and M.
Recamier, prove beyond dispute, that  the ordinary ligature is not al-
ways dangerous in  such cases.  By means of excision we give more
prompt relief to the patient.   As the ligature can  have no  other
object in view than to prevent  hemorrhage,  we cannot perceive
what advantage at least, there would be in assigning to  it the office
  vol. in.                    65 
514
NEW ELEMENTS OF OPERATIVE  SURGERY.
of separating the organ entire.  If, therefore, we adopt strangulation
either in its  simple form  or  after having separated the root of the
body which is  to be  removed, into  several portions, it would, as it
appears  to me, be advantageous to excise immediately  the  entire
mass, which is situated below the  constriction.   This is the way in
which Baxter, Bernhard, and  a great  number of others have operated.
Nothing more would  be necessary to avoid wounding the intestines
or excretory apparatus of the urine,  than to make some movements
on the pelvis, by elevating it  upon the bed  a little higher than the
rest  of the body.   Moreover, the pain, which is caused by pinching
the intestines, the only accident  of  this  kind that the most delicate
degree of attention  does not always  enable  us  to  prevent, will
point out the mistake sufficiently soon,  to enable  us  easily to ap-
ply a  remedy  without delay, and  unless the  constricting thread
should be carried  very high up, as  it was by  the  charlatan men-
tioned by Ruysch, the bladder  and the  urethra  will  be always
placed out of any danger.  The multiple  ligature, which  has  un-
questionably the same advantages in these cases as in epiploic her-
nias, causes less pain  than an ordinary ligature, because it produces
fewer tractions, and puckerings on the root of the organ, divides the
parts  more rapidly, and is less exposed to slip and lose its hold,
when excision  is performed  at the same time.
  b.  The excision of a uterus which  has been for a long time pro-
truded, nevertheless appears to me more worthy of general adoption
than the ligature.  The only danger  which accompanies it is hemor-
rhage.  But the vessels contained in the pedicle of the tumor  are
of sufficiently small size not to give rise to any serious  apprehension
in this respect.  Moreover, what would hinder our making use of the
ligature upon them should it seem proper, or from employing topical
astringents, tamponing, and cauterization  with the hot iron ?  Exci-
sion, which is less painful  and more  prompt, possesses  incontestable
advantages over strangulation, and must necessarily procure a great-
er number of successful results.   This was the process employed in
the patients whose cases  are related  by Pare, Bernhard, &c.  Fur-
thermore, I do not see what we should gain by imitating M. Lano-en-
beck.  The female he  operated upon had a partial prolapsus with
scirrhous degenerescence, like  those of Ruysch, and MM. Hosack,
Wolff, Fodere, and Recamier.  This  surgeon deemed it advisable to
dissect cautiously the  whole of the uterine peritoneum, from the  ex-
terior  to the interior, so that after  the  removal of the organ this
membrane was  found  intact.   It  is  true  that his patient recovered
perfectly, and that she is still  living at the present day.  The intro-
duction of the  air into the cavity of the abdomen  through the va-.
gina, a thing which is  considered  possible  even after  the cure, by
Rousset, who mentions an example, and dangerous  by  Siebold, who
ascribes  to  this the  death of one of his patients, would then be
effectually prevented.   We would remark,  in  the  first place, that
what has been said on this last branch of the subject, is confined to
bare assertions, which may be easily refuted;  and in the second
place, that if  it  were necessary to follow the process of M. Lan ^en-
beck, excision would become one of the most tedious and difficult of
operations. 
EXTIRPATION OF THE  UTERUS.
515
                 § II.— The Womb not displaced.

   If we may believe Lazzari, the complete removal of a uterus which
 was not displaced, was performed in three instances by Monteggia,
 about the beginning of the present century.  De Siebold also states
 that Osiander, the  father, performed this operation in one instance
 with success.  It appears certain at least that on the 13th April, 1812,
 this operation was actually performed by Paletta; but it was through
 a mistake on his part; the author wished  to remove only the neck
 which had become cancerous, and did not perceive that he had  de-
 tached the entire uterus, until on  examining it after the operation.
 It  is therefore to Dr. Sauter of Constance, that  we are indebted for
 having first suggested the idea of this operation,  and for  having per-
 formed it.  In this  point of view, we may now ask the question, if
 extirpation of the uterus be in reality practicable, and whether  it is
 useful, and in what way it may be attended with danger., A word
 or two on each of the cases which we now  possess, will  enable  the
 reader to form a correct judgment on these  different points.
   A. Examination of the facts.—The patient of M. Sauter, (Bull, de
 Fer., t. II., p. 321—Arch. Gin., t. V., p. 616,) who was operated upon
 on the 22d Jan., 1822, died four months after, and from, the author
 says, aparalysis of the lung; the bladder had been wounded.  On the
 5th Feb., 1824, M.  Hoelscher repeated the operation of the surgeon
 of Constance, and death took place at the expiration of twenty-four
 hours.  The patient operated upon by de Siebold on the 19th April,
 1824, survived only sixty-four hours  ; and the one operated upon by
 M. Langenbeck on the 11th January, 1825, died  at the expiration of
 thirty-two hours.  The second woman who was  thus operated  upon
 by de  Siebold on the 25th July, 1825, died on the following day.  On
 the 5th August of the same  year,  M. Langenbeck, (lb., t. XVIIL,
 p. 73—Diet, de  Chir. de Rust., t. VI., p. 697,) performed extirpation
 of the womb a second time, and  the woman^who died fifty hours
 after, exhibited, like the preceding cases, indisputable evidences of
 abdominal inflammation.  Of the four patients operated upon by M.
 Blundell, (The Lancet, 1829, vol. I., p. 618,) since the  19th February,
 1828, three died, one at  the expiration of thirty-nine hours, a second
 after nine hours, and the third very  suddenly, without our knowing
 precisely what kind of lesions were  found  upon the  opening of the
 bodies after death.  The first case, which had  been considered as
 cured, died a year after  at  Guy's  Hospital from  a return of the
 cancer.
  The case of M. Banner (Journ. des Prog., t. XIII., p. 272,) opera-
ted upon on  the 2nd September, 1828, died on the  fourth day of a
peritonitis.  M.  Lizars was desirous of repeating the operations of
his two countrymen, and the patient whom he operated upon on  the
2nd October, 1828, also died in the space of  24 hours.  M. Langen-
beck repeated the operation in 1829,  and his patient survived but 14
days.  On the 26th July, 1829, M.  Recamier performed this extirpa-
tion for the first  time in France.  It was to this surgeon that appear-
ances promised the  most perfect success from it,  but he nevertheless
had the misfortune,  like M. Blundell,  to lose  his patient at  the  expi-
ration of a year.  Another case was  operated upon by M. Roux, on 
516
NEW ELEMENTS  OF OPERATIVE SURGERY.
the 20th September, 1827, and this one died on  the evening of  the
next day.  He had opened into the bladder.   Some days after, Pro-
fessor Roux extirpated the uterus a second time, and death took place
at the expiration of 25 hours.  M. Recamier again performed it on
the 13th January. 1830, and the woman died in 33 hours.   M. Dubled,
(Arch. Gen. de Mid., t. XXIII., p. 403.) on his part, performed the op-
eration  on the 20th June, 1830, and the patient survived but 22 hours.
Delpech also, who thought proper to make trial of it, was not more
fortunate than the  others, and his patient died on  the third day.   Fi-
nally, the English journals  have furnished another case, which  be-
longs to M.  Evans, and which is said  to  have succeeded; but I do
not possess a sufficient number of details on this subject to dwell upon
it  at greater  length.  A patient operated  upon  by M. Granville,
(Journ. des Prog., t. XIII.,  p. 270,)  had a return of the cancer.
Without comprehending, therefore,  in  the  above list,  the doubtful
cases of Monteggia, Osiander, &c, we have, in  adding the case of
Paletta, whose patient died  on the third day, of an intense peritonitis,
twenty-three authentic, indisputable instances of extirpation  of  the
uterus, performed during the last 20 years, and out of this number
not a solitary permanent cure !  Can there  be anything  in surgery
more frightful ? and the results of such  a  melancholy catalogue, are
they not of a character to banish this operation forever from practice ?
Among  the dangers which it involves,  that of peritonitis is placed in
the first line.  This inflammation, nevertheless, has not always  oc-
curred.   The patient of M. Sauter, and those of MM.  Blundell and
Recamier, who all survived, were not attacked with it, and the  bodies
after death, in some of those who died in the beginning, presented no
traces of it.  It is to be added, that in the women  in whom death has
taken place most rapidly, for example, in less than 24 hours, the peri-
tonitis could not have yet had time to become developed, even though
it might have been a necessary result of the operation.   Hemorrhage
is another accident v^hich is necessarily attended with danger ; it oc-
curred in several of the patients, as I witnessed in one  of those ope-
rated upon by M. Roux, and in another by M. Recamier,  and has been
noticed  also in Germany and England.  It  has not, however, taken
place in the  great majority  of cases.  Some of the women, it is said,
died from exhaustion produced by the pain and suffering.  The ques-
tion occurs,  why those who escaped the immediate consequences  of
the operation, and  this first  and violent onset, have remained in a lan-
guid condition, and ultimately succumbed.   In their cases the opera-
tion could not be  charged with having produced either  peritonitis,
hemorrhage, or pain.   The patient cited by Vieussens, who survived
15 years, that of M. Marschall, who did not die until after the expira-
tion of 10 years, and that of M. Langenbeck, who is still living, &c.
and in all of whom the protruded uterus was removed, are  a sufficient
answer  to the objection of those surgeons who consider that  the  pa-
tients whom I have just spoken of owed their death exclusively and
solely to the extirpation of the uterus.
  B. Indications.—What chances of success have we from extirpa-
tion of a uterus which  has  become cancerous, and when the  opera-
tion is performed under the only conditions in which it is admissible ?
Were we to undertake to describe those conditions, we should find  the 
EXTIRPATION OF THE UTERUS.
517
it would be a difficult matter, and that their combination must neces-
sarily be a rare occurrence.   So long as the cancer has not attacked
the whole organ, pure  and simple excision, from  enabling us to go
very high up, ought  to be deemed sufficient.  It  was by  means of
excision that M. Bellini (Journ. des Prog., t. XII., p. 273,) extirpa-
ted the lower half of the uterus in 1828, with entire success.   It was
also excision which M. Dubled proposed  as a substitute for extirpa-
tion, (Arch. Gen. de Med., t. XXIII.,  p. 142.)  When, on the contra-.
ry, the disease has involved the whole organ, how can we be sure that
it does not  exist in  any other ?  It  is certainly very true, that the
finger successively introduced into the vagina and rectum, while the
other hand rests against the hypogastrium. will frequently enable us
to conjecture that there may or may  not exist some decided degener-
escence in the pelvic cavity, in the region of the ovaries, or Fallo-
pian tubes, or in  a word, in  the connections or neighborhood of the
uterus ; but under this point of view, the most skillful surgeon can
only acquire probabilities of greater or less force,  and never absolute
certainty.   How then, with  such data, can we decide upon perform-
ing an operation  so formidable !  Upon the supposition even that the
womb only is affected, it would be necessary at least that it should
have preserved its natural mobility,  and  be free from morbid adhe-
sions,  without which the operative processes at present known would
be  scarcely admissible.  But so long as it remains in this  state, it is
not probable that the  cancer has attacked it throughout its whole
extent, and  then the idea of  excision suggests itself to the mind. How
also can we decide,  when the disorganization is not  very far  advan-
ced, that the body of the uterus is actually in a cancerous condition,
or that it is a little larger or  a little less than in its normal state, see-
ing that we have  no  other means  of judging than by the fingers,
through the walls of the belly, rectum, or vagina ?
  C.  Operative  Methods.—Two principal methods  have  been pro-
posed for extirpation of the  uterus, one which may be called  the hy-
pogastric, the other the infra-pubic
  I. By the hypogastrium.—To believe Musitanus, extirpation of the
uterus at the hypogastrium is far from being a new operation.   This
author, in fact, on the authority of Wier,  asserts that a girl who was
excessively  libidinous  was  operated upon  in this manner by her
father, who  made an incision at the lower belly, and through this
wound reached  the  uterus,  which he instantly excised.  But it i3
probable that the peasant mentioned  by Musitanus confined himself
to the removal of the ovaria without disturbing  the womb itself, in
the same way as  the operation  is performed  upon the female of do-
mestic animals.   The same  remark  is applicable  to  the passages in
Aetius, Schurigius, &c, where we find it mentioned that surgeons
had opened the belly  in  certain women in order to  extirpate the
uterus.  However this may be, the hypogastric method was described
and distinctly recommended  in 1814 by M. Gutberlat, (Rust's Handb.
der Chir., vol. VI.)  M. Langenbeck I believe is the first who ven-
tured to apply this method on the living person.   Slightly modifying
the process of Dr. Gutberlat, he deemed it advisable  first to open the
peritoneum through  the vagina, in order to be more certain of avoid-
ing the bladder.   This method was made trial of in France by Del- 
518
NEW ELEMENTS  OF  OPERATIVE SURGERY.
 pech.  If it were ever possible to demonstrate that large openings in
 the walls  of the belly could be  unattended with danger, there  is no
 doubt that the hypogastric method improved would ultimately render
 extirpation of the uterus quite an easy matter.   But to combine it
 with the infra-pubic  method  is not  the way to secure  its  adoption,
 anv more than the incision in  the perineum, as proposed by b. Come,
 was calculated to give  popularity to the operation of lithotomy by
 the high method ; we have enough already with one of them, without
 endeavoring also to combine them both together.
   II.  By  the  vagina.—Out of twenty-three known instances of abla-
 tion of the uterus, twenty-one  have been effected by penetrating from
 below upwards.  M. Sauter being unable to bring down the organ
 as Osiander did, divided as he continued upwards, and by means of
 small cuts, the vagina on the anterior surface of the neck, succeeded
 by this mode  in effecting the anteversion of the uterus, and was thus
 enabled to separate'in succession the two broad ligaments, and to
 terminate  the operation by gradually isolating  the uterus from the
 rectum.   MM. Hoelscher and Siebold operated nearly in  the  same
 manner.   In one instance, however,  the last mentioned surgeon was
 obliged to incise the vagina laterally in order  to facilitate his move-
 ments and the introduction of his hands.  M. Langenbeck commenced
 by incising the perineum from  before backwards; he then divided
 the vagina behind, in front, and on its sides;  and finally grasped the
 uterus at its fundus and completed its separation by a careful dissec-
tion.  M. Blundell detaches the vagina posteriorly, and penetrates in
this manner into the recto-uterine fossa of the peritoneum ; afterwards
 seizes the  fundus of the uterus, retroverts  it, divides the broad  liga-
ments and terminates by separating  it from the bladder.  M. Banner
preferred  turning over the organ upon its side, after having detached
it  behind  and in front and from one of its broad ligaments, rather
than reverse it  upon  one of its faces.  He terminated his operation
by dividing the other broad ligament.  The incision of the perineum
introduced in practice by M. Langenbeck, was extended as far  as to
the rectum by M. Lizars, who then  divided the vagina on the two
faces of the diseased organ, before reversing it.  M.  Recamier and
 M. Roux  have followed  with  two modifications the  process of M.
 Sauter.   If it were possible to introduce  one of the  tractor instru-
 ments above mentioned,  M. Recamier would recommend its employ-
 ment,  but if not he would prefer introducing into  the uterus the
 branch having two prongs of an erigne forceps, the other branch of
 which should have three prongs, and be applied as high up as pos-
 sible on the outer side of the neck.  If this cannot be done he recom-
 mends  that we  should have  recourse  to  Museux's  forceps, either
 simple or articulated, like the common forceps, or bent into the shape
 of a Z, or merely at a right angle as M.  Tanchou  proposes, at the
 outer  third of their  handle, in order that  the  parts may not be too
 much  concealed by them during the  remainder of the operation.  By
 means of  one or the other of  these instruments we are to bring the
 cancer down as low as possible.  A straight  bistoury protected  by
 the hand,  detaches from  below upwards the vagina  from the  front
 part of the neck, then from the womb itself, until we arrive very near
 the peritoneum, which is then to be opened.  The bistoury, which is 
EXTIRPATION OF THE UTERUS.
519
to be  constantly guided by the finger, and  operating through the
peritoneal opening successively to the right and left, will enable us to
detach completely the anterior surface of the organ from the fundus
of the bladder, and to expose the roots of the broad ligaments.  The
forefinger glided above the fallopian tube, readily passes upon the
posterior surface of the peritoneal duplicature, enables us to divide
from above downwards the entire thickness of this fold as far as to
its lower third, and to embrace the remainder of it in a strong  liga-
ture.  After having done the same  on the opposite side, M. Reca-
mier terminates the  section of the broad  ligaments, reverses  the
uterus forward, and finally separates it from the rectum, conducting
his incision from above downwards.  M. Gendrin proposes that the
uterus should be successively isolated throughout  its whole  circum-
ference, and turned upon its axis, rather  than reversed, when we
have arrived at the end of the operation.   In place of applying his
ligature below the insertion  of the fallopian tubes as M. Recamier
does, M. Tarral, (Journ. Hebd., t. V., pp. 403, 529,) on the contary,
commences by embracing with it the  whole of the broad ligament,
making use of a curved  needle, like that of Deschamps, in order to
introduce it, and of his left forefinger  and thumb to guide it in  its
progress.  M. Dubled considers, that, after having brought down the
uterus as much as possible and detached the adhesions of one of the
broad ligaments, to the right and in front, and then posteriorly, and
after having passed a ligature below the root of the fallopian tubes,
through the lateral ligaments, in order to include their twro lower
thirds, and to enable him to divide them between the ligature and the
uterus, it would be an easy matter to amputate the uterus nearly as
far up as to its  fundus or superior border, in such manner as  to leave
the fallopian tubes, ovaria, and round ligaments in their place, and
even also without the necessity of opening into the peritoneal cavity.
But  it is evident that this process has then no more to do with the
complete ablation of the uterus, and that it is only an improvement
of the method of excision such as it was performed by  M.  Bellini.
This last surgeon, (Strangulamento uter. porter., &c, 1835—Methode
pour extirp. Vutir., &c, 1837,) who passing posteriorly by the cul de
sac of the vagina, applies  the noose of a ligature above the  uterus,
which last he then strangulates from  above downwards through the
interior of the  peritoneum, must necessarily have been arrested  by
the fallopian tubes and the broad ligaments.
  III.  To assert now which process is the best among all these modi-
fications, would  be attended with so  much the more  difficulty from
none of them having been  followed by  a decidedly successful result,
and from the fact that the apparent cures in certain women have been
obtained from different processes.   Thus the  case of M. Sauter, in
which the uterus was reversed forwards, survived four months; that of
M. Blundell, which survived a year, was operated upon by reversing
the uterus backwards ; and the patient of M. Recamier, who remained
cured for a  year, had been submitted to the first  process of this au-
thor.  As to the modifications proposed by MM. Gendrin and Tarral,
I  do not consider it necessary to discuss  their advantages or incon-
veniences.   Moreover, as no  person will undertake the operation  (if
in fact it is ever repeated) without deeply reflecting upon it, it is proba- 
520
NEW ELEMENTS OF OPERATIVE SURGERY.
ble that every one will consider himself entitled to make still further
modifications upon these different methods ; so that I should be fear-
ful of abusing the patience of the reader in examining in greater de
tail those which I have briefly described.

            Article XL—Vesico-Vaginal  Fistulas.

   Vesico-vaginal fistula, notwithstanding its frequency and the acci
dents it occasions, as well as the repugnance it creates, has not been,
up to the present time, (1831,) submitted to but to quite a small num-
ber of  the resources of surgery.   Whether it be congenital, (Diet.
des Sc. Mid., t. LVI., p. 303,) or the result of severe parturition, or
injurious obstetrical  manipulations, or  a gangrenous perforation, or
a contusion  or  traumatic  lesion  of any description  whatever, it is
nevertheless a  disease which but rarely disappears  spontaneously;
the small vesico-vaginal fistulas  only will get well, says Mauriceau,
but the larger ones  are incurable.  The small number of spontane-
ous cures related by Peu and MM. Blundell, Ryan and Paletta, (Ba-
zard, These, No.  190,  Paris, 1834,) and the  little success that  has
attended the attempts that  have been  already made, is not a suffi-
cient justification for the almost absolute silence  of our best authors
on this subject.   Various  kinds  of remedies,  nevertheless, may  be
had  recourse to for this  affection.

                         § I.—Suture.

  The  suture, which must have  first suggested itself to the mind, is
of such difficult application that but few practitioners have ventured
to make trial of it, so that scarcely any mention is made of it in the
works which have issued from the school of  Paris.  To abrade the
borders of an opening when we  do not know where to grasp them,
to shut it up by means of needles or threads when we have no point
apparently to sustain them, to act  upon a movable partition placed
between two cavities hidden from our sight, and upon which we can
scarcely find any  purchase, has appeared to be calculated to have no
no  other result than to cause  unnecessary suffering to the patient.
Roonhuysen, who, according to M. Chelius, was the  first to recom-
mend the suture, did not make use of it.  If I understand  the matter
correctly, it was his nephew who spoke to him of it, and who con-
siders that after having abraded the borders of the division, we may
perforate them and keep them in contact by  means of a quill cut in
the form of a point.  The  cures which this method  is said to have
obtained in the  hands of Fatio, Walter and Schroeger, are not sup-
ported by sufficiently conclusive proofs to carry entTre conviction to
the mind.  Experiments, however, which were made by M. Nsegele
(Journ. Univ. des Sc. Med.,  t.  VII., p. 160,) in the year 1812, led us
to hope that it  would succeed, while M. Erhmann" has since' had a
proof of this success in a patient which Flamant confided to him
and the thesis of M. Deyber (Journ. Hebdom., t. IV., p 241) shows
us  that like this  last surgeon he was no  less fortunate himself in
a second case.  The fistula, which was very  large in one case and
narrower in the other, did not nevertheless cicatrize until after  the 
VESICO-VAGINAL FISTULAS.
521
separation of the threads and a suppuration, which  was prolonged
for a considerable period of time,  so that the cure did not take place
in consequence of the immediate contact of the parts.  In 1828, M.
Malagodi of Bologna performed it with no less success, and the un-
fortunate result which it met with in the hands of M. Roux, (Repert.
d'Anat.et de Phys., &c, t. V., p. 147,) in the year 1829, at La Charite,
speaks nothing in reality either for or against it, inasmuch as the symp-
toms which preceded the death of his patient, were altogether dis-
connected with those which would naturally  belong to the suture ;
cures moreover, it is said, have since been obtained from it by MM.
Hobard, Charnham and S. Cooper.
   A.  Interrupted  Suture.—M. Malagodi,  after  having caused  his
patient to be laid on the bed and held in the same manner as in the
operation for stone, introduced the extremity  of his forefinger,  pro-
tected by a leather finger glove, into the bladder through the vagina
and the fistula, and then made use of it as a hook to bring out one of
the lips of this last to the vulva, and to exsect its callous portion with
a  straight bistoury; having done the same for  the other  side by
changing  his hand, he then attended to the insertion of the threads.
M. Malagodi, for the second  stage  of the operation,  again seized
one of the borders of the wound  as  before, with the left forefinger,
introduced near its  posterior extremity a small curved needle, at
the distance  of two lines outside of it, brought this out by a cir-
cular movement from the  bladder  into  the  vagina  by making it
pass through the  vesico-vaginal  septum,  and was  thus enabled to
disengage  it immediately afterwards.   The  second  needle, fixed
at the other  extremity of the ligature, was also  introduced  through
the fistula and  brought out from the bladder to the vagina, to be
disengaged like  the preceding.  The surgeon applied  a second and
then a third thread in pursuing the same method, then  knotted them
separately in  such manner as to effect an exact coaptation, and termi-
nated by  cutting their extremity near each knot with the scissors.
A catheter was  kept  in the bladder and  the  patient made to  con-
tinue  in bed.  During the first and succeeding  day the  urine  ran
wholly through the catheter, but on the third  it was perceived that
some few drops of it had passed into the vagina.   The  two posterior
points of suture had succeeded perfectly.   A  single one, that which
was nearest to the urethra, had torn out from  the tissues, but it was
not deemed advisable to reinsert it.   Cauterization with the nitrate
of silver, repeated at different times, terminated the cure, which was
completed at the expiration of a few weeks.
   B. It was  the twisted and not the  simple suture  to which M.
Roux deemed it advisable to give the preference.   In order to abrade
the fistula he made use of forceps very nearly similar  to the disc of
chimney tongs, after the half of the disc had been removed.  One of
the lips of the perforation having been  grasped  by this instrument,
M. Roux was enabled to exsect it by means of a bistoury, and could
have  done so also with a long pair of scissors.  The suture  was
passed from the vagina into the bladder, and first through the left lip
by means of a curved needle and the ordinary needle-holder.   This
needle was then brought from the  bladder into the vagina  through
the other Up  of the fistula, then drawn  to the outside, dragging after
   vol. in.                     66 
522          NEW ELEMENTS OF OPERATIVE SURGERY.
it through the two lips of the wound a small metallic stem, fixed at the
extremity of the ligature.  Three of these were successively inserted
with  the  same  precautions; after  which the  noose  of a ligature,
passed upon the first needle, adjusted and  crossed successively on
each of the others, as is done in harelip, allowed of the  approximation
of the bleeding surfaces, and finally the completion of the twisted
suture.  Symptoms of intermittent fever, and  afterwards of functional
derangements of the brain, and of inflammation of the peritoneum and
pleura, began to show themselves after the  lapse of a certain time,
and became so serious  that this woman died in the space of about
twelve days.  Upon opening the dead  body there was found a con-
siderable enlargement of the fistula, the  lips of which had in no place
contracted the slightest  adhesion together.
  C.  The method adopted  by 31. Schreger, though less judiciously
arranged, had nevertheless  less unfortunate results.   It  has been
incorrect, however, to.state that the cure was complete; the suture
was performed three times ;  and the words of the author himself suf-
ficiently point out that the patient was not cured after the third appli-
cation : " I was satisfied," says he, " that the wound  was perfectly
cicatrized, except for about  the space of a line, where it was difficult
to incise the borders.  The  patient found herself considerably better,
and I  had even flattered  myself that I should obtain a perfect cure in
a fourth  trial,  when indispensable matters  obliged  her to  leave
Erlangen."
  D.  The condition  of  the female operated  upon  by Duges, (Bull.
de Ther., t. II., p. 145,) was  rendered worse, rather  than ameliorated,
by the suture.  Nor  did the  young girl, who was  sometime  in  my
department at La Pitie and upon whom M. Robouham made similar
trials,  derive any decided advantages from them according to what
M. Mondiere tells me, who was  present at the operation.  It is use-
less therefore to enumerate in this place the details  of the process
employed  by these  practitioners.  Unless the fistula  be extremely
large, the forefinger cannot seize its lips in the manner  of the surgeon
of Bologna, nor reach them with the forceps in the manner performed
by M. Roux.  The longitudinal divisions only could be treated with
the suture after  the manner of these two  surgeons.   But experience
shows that vesico-vaginal fistulas constitute  in most cases a trans-
verse  fissure, or even a kind of half moon  with  its concavity for-
wards, between  the urethra and  the entrance of the ureters into  the
bladder.
  E.  If the instrumental apparatus of M. Naegele was not so com-
plicated, it would certainly offer  more  chances of  success than  the
preceding processes, though  this  also is scarcely  applicable  but to
longitudinal openings.  But art  requires something more simple  for
the suture to be generally adopted.  M. Schreger by abrading so to
speak, only the posterior half of the fistula, and introducing each point
of suture at only a line or two from the bleeding borders? considered
himself exceedingly fortunate in  being enabled almost to effect a
complete cure of his  patient, and to  obtain so  successful a result in
the three trials he made.
  F.  The author.—Trials made  upon the dead body  induce  me to
believe that we  should succeed better in adopting the following me- 
VESICO-VAGINAL FISTULAS.
523
thod.   I cause the patient to be placed upon a bed, or upon  a table
sufficiently elevated and  properly arranged.  A round-shaped mat-
tress is placed under the belly, in such manner as to  enable  her  to
keep her thighs flexed while lying upon  her abdomen.   An assis-
tant keeps the vagina dilated by means of a  large gutter of metal,
horn,  or thin wood.  With  one cut of a  straight pair of scissors, I
enlarge the fistula a  line or two in extent posteriorly, and do the
same  on its anterior  angle  with a narrow bistoury, in order to be
enabled to seize each lip successively with a good pair of staphylo-
raphy forceps, and to excise a strip from them by means  of  scissors
that are straight or slightly  curved flatwise.   The points of suture
are then introduced at three or four lines outside  of the abraded sur-
faces.   In order to support the parts, the forceps replace the thumb
and forefinger of the  left hand, while small needles are  introduced
through the borders of the fistula in the manner they are inserted by
M. Roux or M. Malagodi.   Finally, each thread is knotted  at the
bottom of the vagina by  means of  the fingers.  If the cleft is trans-
verse, a bistoury curved  flatwise near its point, and very sharp, and
introduced through the  vagina, very readily detaches a strip from
its deep-seated border, which also is to be kept reversed or depressed
by means of an erigne or good forceps.
   G.  Moreover, if the suture of vesico-vaginal fistulas succeeds with
so much difficulty, and constitutes so embarrassing an  operation, per-
haps we ought to charge it on the  imperfections  of the instrumental
apparatus.  At  the present day,  when  by means of the spiroidal
needle of M. Colombat, we  may in one  operation introduce  a whip
suture in  any part of the vagina whatever ; and when by enlarging
the urethra with a double lithotome, as M. Sanson has done, in order
to enable  us  to  introduce the finger by this  route, and to seize the
fistula so as to depress it  towards the vulva;  and when by means  of
the needle-holding forceps  of M. Bineau, M. Soteau, M. Beaumont,
M. Bourgognon, or M. Foratier, we may  readily pass  such  number
of points of suture around the fistula as we may desire, without any
serious difficulties; we have, as it would appear to me, a further pros-
pect of effecting cures, and  sufficient grounds to justify new trials in
this treatment.  If, as M. Erhmann, (Begin, Elem. de Chir., 1.1., p. 442,)
has successfully done, M. Sanson, who endeavored to close the open-
ing by a sort of pucker ;  M. Leroy who  had recourse to five or six
different processes; M. Buret who passed his threads by means of
a needle, directed along the  urethra through  the vesico-vaginal sep-
tum ;  and other surgeons of Paris who  have endeavored in latter
years to cure vesico-vaginal fistulas by  the suture,—have not suc-
ceeded, there is  reason to believe that the irregularities of the abra-
sion, or of coaptation, have  been the cause of these failures, and that
the instruments  of M. Coglioso would give greater  facility  to this
stage  of the operation.  The  apparatus  contrived  by  M.  Fabbri,
(Memoria intorno alcuni nuovi instrumenti, &c, 1838—Soc. Med.
Chir. of Bologna, vol. II.,) to abrade, approximate, and suture the
lips of  vesico-vaginal fistulas, whether oblique  or transverse, is un-
doubtedly ingenious, but  scarcely adds to the  chances  of a favorable
issue to the operation. 
524
NEW ELEMENTS OF OPERATIVE  SURGERY.
             § II.—Process of M. Lewziski.—Ligatures.

    Several surgeons, convinced of the difficulties which I have just
  pointed out, have directed their attention towards  another mode of
  treatment.  To bring the posterior border of the fistula at the same
  time towards the urethra, while its anterior border would be crowded
  backwards,  was the first idea which seemed to open the door to suc-
  cess.  M. J. P. Lewziski  had endeavored  to lay down this principle, in
  the year 1802.  The instrument which he recommends is a flat canula,
  somewhat curved, and pierced near its extremity with two openings
  for the passage of a needle, which is  also curved.  A  stilette or
  spring, enclosed in this canula, is designed for pushing the needle into
  the passage  of the vagina, through the posterior lip of the fistula, as
  soon as the canula is placed in the bladder.  This needle, withdrawn
  through the vulva, drags after it a thread which is made into a noose
  or point of suture.  After having adjusted several of them in the
  same manner, they are passed into a knot-tightener, in order to  close
  up the vesico-vaginal opening. This apparatus was not applied  upon
  the patient for whom M. Lewziski had contrived it.

                        §  III.—Erignes.

   In 1826, M. Lallemand (Arch. Gen. de Med., t. VII., p. 481,) pub-
 lished  a case of ancient vesico-vaginal fistula, cured by means of an
 instrument, the principle  of which has some analogy with that of M.
 Lewziski.  The apparatus of the professor  of Montpelier, is compos-
 ed, in fact, 1st, of a large canula about 4 inches long ; 2nd, of a double
 hook, which is moved in  the principal instrument by  means of a stem,
 in such manner as to push it out, or to make it enter into its sheath;
 3d, of a circular plate  which terminates  the other extremity of the
 canula, and which would hinder, if necessary, this latter from pene-
 trating  too deep into the urethra; and 4th, of a cork-screw sprimr,
 (ressort en-boudin,) intended to draw forwards the small hooks as soon
 as they are inserted m the  posterior  lip of  the fistula.   It is applied
 also in the same manner  as I have just stated in speaking of the pro-
 cess of M. Lewziski.  The canula being passed into the bladder, al-
 lows of our pushing the two small hooks into the vagina through the
 yes co-vaginal septum, which latter is supported by the left forefinger
 By making a turn  of  the  screw, they are kept  in  this pos'tion"  a
 pledget of  lint, or fine  linen, designed  for  protecting the  slues' is
 then placed between the front part of the urethra a^d the extorna
 plate of the canula; finally, we relax the  spring, which acts then a
 the same time by making traction on the  posterior lipwi?its hook,

 Tf ^^^^TtT^^ the -ethraby means
 Bya^                                     point kppui.
 late the stop of the spring in JK^^/S
 from it a moderate degree of pressure thono-h «„«„• w;u.on[y.result
the two borders of th/fistu.a iL^^^^^Q


cape into the  vagina, id ins^tC ^^7^5 
VESICO-VAGINAL FISTULAS.
525
brown spot was observed upon its lower surface, at the distance of
four lines in front of the hooks.   The  fistula nevertheless, appeared
to have considerably diminished  in its extent.   Another application
was now made with the erigne canula, and this time the reunion ap-
peared to be perfect.  Nevertheless, some imprudence committed at
the expiration of about ten days,  enabled the urine to escape into the
vagina.  A  very small disunion  had taken place, and  the surgeon
supposed that he could complete  by means of cauterization a cure to
which his instrument had so greatly contributed.  Sometime after-
wards they  wrote to him that nothing any longer escaped through
the fistula, and that the cure appeared to  be complete.   The opera-
tion having  been commenced and terminated with the nitrate of sil-
ver, the use of which alone counts at the present day several unques-
tionable examples of success, this fact was  in reality much less con-
clusive than it was at first supposed to be.   A similar attempt  was
made with the same apparatus in the course of the year 1829, at the
Hospital Beaujon.  The success which was  at first anticipated  was
not sustained, and the patient soon found herself in the same condi-
tion of infirmity as before.   M. Lallemand, however, (Arch.  Gen. de
Med., 2nd ser., t. V., p. 482,) in  publishing  another case of success,
appeared to be very much annoyed with the doubts expressed in re-
gard to his first patient, Mdme. Martin, of Marseilles, who continues to
remain effectually cured.  The lady, who has been seen at  Paris, had
deceived him herself, and is the subject of another observation.  I re-
ceived from him, on the 2nd October, 1837, the positive assurance on
this subject, that out of 15 or 16  trials, he had  obtained  six or seven
cures, two of which moreover have been published by  M. Deville,
(These, No. 107, Montpelier, 1833.)

                             §  IV.

   The instrument which Dupuytren used in one instance with  suc-
cess, and which is a sort of large cannla, or female catheter, has on
its sides two opercula or guards, which open like two wings, or  shut
up entirely, according as we draw to the outside, or push inwards  a
central stem in the form of a spring, which performs  the office of
moving them.  It is introduced shut up in the bladder.  The opercula
being once  opened and fixed in their place, we then make traction
upon  the instrument towards us,  as if for the purpose of withdrawing
the whole of it. From the guards preventing it from being withdrawn
from the urethra, it brings with it  in front the posterior lip of the fistula,
while the lint  or linen placed between the urethra and external plate
of the canula, enables it to  crowd the urinary passage backward.
This process,  which has neither the inconvenience of perforating or
lacerating the vesico-vaginal septum, and which  moreover is infinite-
ly less complicated than the preceding, would without doubt be soon
decisively adopted, if it was  in reality  calculated to effect the perfect
coaptation of the borders of the fistula; but this is not the case, and I
doubt if it can be used in any other way than as an adjunct to cau-
terization. 
526
NEW ELEMENTS OF OPERATIVE SURGERY.
                 § V.—Process of 31. Laugier.

  If the suture is rarelv applicable except to longitudinal fistulas, it is
evident that the erigne'canula in its turn is only suitable to transverse
fistulas.  M. Laugier. with the view of obviating this difficulty and to
make the method of M. Lallemand applicable to all kinds of fistulas, has
had constructed an erigne forceps, which is jointed after the manner of
a Smellie's forceps, and the form of which is modified according to the
kind of fistula.  If the case is one of a transverse fistula, the prongs of
the instrument are bent into an angle on one of its sides directly up-
wards, one to the right, and the other  to the left.   In longitudinal
fistulas, on the contrary, the two hooks of each prong must be paral-
lel to the axis  of  the body, while the extremity which supports them
is bent into an angle on the border.   Finally, we should bend the for-
ceps obliquely, if the fistula itself had  this intermediate  direction.
The hooks of this forceps, says  M. Laugier, should be very short, in
order that they may not go through  and through the vesico-vaginal
septum.  They are introduced through the interior of the vagina, and
not through the bladder.  Those of one of the branches are  inserted
at some lines outside of the fistula, which has been previously abraded.
Those of the other are applied in the same  manner on the opposite
side; after which they are approximated  by shutting up the  forceps.
In order that this  approximation may be  graduated, augmented or di-
minished at pleasure, a screw is made to pass  through the two han-
dles  of the forceps, nearly in the same manner as in the enterotome
of Dupuytren.  The whole is protected  by means  of lint, properly
arranged in the interior of the vagina, or at least  in  the opening of
this passage.   The process of M. Laugier, whenever it has been put
in practice on a living  person, has always failed  up to the   present
time, and I doubt if it in reality possesses any great degree of efficacy.
It is difficult to conceive, that  upon a partition  so movable, simple
hooks would be sufficiently steady to keep in exact  contact, during
the space of three or four days, the two lips of a  fistula of any con-
siderable extent.  If they do not go  through the  entire thickness of
the tissues, these hooks will almost unavoidably slip, while  tearing at
the same time the vaginal membrane, or  the urine will become lodged
in the  depression left in the bladder, and will  not  fail to make its
appearance on the side of the forceps.  If they go as far as  into the
bladder, would not the openings they make, and which would be en-
larged  by  suppuration before they could be withdrawn, incur the
risk  of making  additional  fistulas instead  of curing the old  one ?
Then also, the contour  of a vesico-vaginal fistula is far from being
always of the same thickness  on all its different points.  Those for
example, (and these are incomparably the most frequent,) which oc-
cupy the termination of the bas fond of the bladder, are in  general
exceedingly thick in  the direction towards  the urethra, and  very
thin on the contrary,  behind.   It would  be necessary, therefore, for
the anterior  claw of the instrument to  penetrate  to  the depth of
two  or three lines, while the other would be implanted in a lamella
of only a line  or half a line in thickness.   In longitudinal fistulas
the hooks would probably affect only a partial coaptation,  since their
contour almost always presents some points that are more  resistant 
VESICO-VAGINAL FISTULAS.
527
than others.   Finally, for fistulas that are more remote, would not
the suture be attended with more certainty, or would it be much
more difficult to execute in practice ?

                      § VI.—Cauterization.

  Cauterization, which at first  sight would seem to be only calcu-
lated to increase the  loss  of substance, is, nevertheless, one  of the
best means which  have been made trial of up to the present time.
(Monteggia, t. V., p. 339, 1st edit.)  Used to the extent of irritating
and of  inflaming the tissues to a sufficiently intense degree, without
effecting  their mortification, it produces  an engorgement and intu-
mescence, which /closes up  or contracts, at  least for the time  being,
the opening which we are desirous of  healing up.  After the  subsi-
dence  of the  engorgement, the  exhalation and suppuration  which
supervene are accompanied with a manifest tendency to coarctation.
This, therefore, is a method which  deserves  all the attention  of the
practitioner, and one  which appears to  be  especially calculated  to
succeed where the perforation has but little extent.  The cauterization
is effected by  means of the  actual cautery or nitrate of silver.   The
concentrated acids, and nitrate acid of mercury, which Dupuytren had
at first  thought of, ought to  be rejected.   The incandescent iron has
the advantage of acting with more  rapidity and with greater energy.
Unfortunately also, it exposes to the risk of forming an eschar, and of
destroying the tissues which we wish  only to inflame.   The nitrate
of silver is generally preferable, and the actual cautery ought  not  to
be  substituted in its  place, except in some particular cases, as for
example, when  the  borders of the fistula are  callous, or cannot be
inflamed without too much difficulty.
  A. On  the  supposition that  we  adopt the red hot iron, we must
commence by introducing  a speculum into the vagina.   The ordi-
nary jointed  speculum is as good as any  other.  If, however, we
should desire to protect the  surrounding parts with still greater secu-
rity, and to leave nothing but the fistula bare, we might make use of
a simple cylindrical  speculum pierced on its side, or the flute-beaked
speculum of Dupuytren, (Journ. Hebd., t. V., p. 256.)  This instru-
ment being introduced in such a manner as to expose the fistula to
view, we pass into  the  opening either a probe heated  to a  white
heat, or a small bean-shaped cautery, while taking care to leave it
there but an instant, or to apply it a second time if the first cauteri-
zation should not appear to  be  sufficiently powerful.  Delpech,  who
obtained a remarkable cure from  this application, thinks that the
cautery should not act upon the  vesical  circumference, but only on
the vaginal portion of the fistula, in order, he says, to avoid the loss
of substance, while at the same time bringing  into full play the ten-
dency to coarctation;  this is a remark which the  practitioner ought
to attend to  in  the trials which  may hereafter  be made  with this
process.
  B.  In using the nitrate of silver,  the assistance of the speculum is
not indispensable.   We should never make use  of a simple  port
crayon  to cauterize with this substance.   For then  it would scarcely
touch any other than the inner surface of the vagina, and would  in 
528
NEW ELEMENTS OF OPERATIVE SURGERY.
 most cases leave the fistula itself wholly  intact.  We fasten to the
 extremity of a dressing forceps a portion of the nitrate, by means of
 a thread, in such manner that the caustic forms a projection at right
 angles to the  border of the instrument.   By means of this forceps
 thus prepared, nothing is more easy than to introduce the lapis infer-
 nalis into the interior of the fistula, and to cauterize the whole of its
 circumference.  A ring surmounted with a small beak destined to
 receive the nitrate, and which could be guided by the extremity of
 the finger protected with leather, would  perfectly  replace  the for-
 ceps, did it not, like the lateral port crayon, constitute  a separate
 instrument.   In  whatever manner  the  cauterization has been effect-
 ed, it is advisable immediately after to  throw up one or more  injec-
 tions into the vagina, and to place the patient in a bath. A catheter
 should be left to  remain in the bladder,  and continue open upon the
 border of a vessel arranged for this purpose in front of the vulva, in
 order that the urine may escape freely  and not be retained.   When
 the inflammation and swelling have ceased, the same operation ought
 to be repeated.  We have recourse to it in this manner four, five, or
 six times, according to  the benefit that results from it, that  is to say,
 until the urine ceases to pass  through the vagina.   Because the fis-
 tula, after being at last reduced to very  small dimensions, appears
 to resist and contract  no  more, we should be wrong  in totally de-
 spairing of success, for in more than one  instance it has been  seen
 to close  up  finally at  the  expiration of a few weeks, though it had
appeared to be no long'er making any progress towards a cure.
  C. Cauterization, either by means of the iron or chemical substances,
appears to have obtained a certain  number of cures in  the hands of
Dupuytren.   M. Sanson, who  was  an eyewitness, gives some exam-
 ples  of them.  An attentive perusal of the case published by M.
Malagodi. also furnishes grounds for believing that in his patient the
lapis infernalis probably had more to do  with the cure than the suture,
 and in the other  cases where the caustic has been used as  an auxili-
 ary or combined with  those means which  have  been considered the
 principal, it is quite possible this application of itself has procured the
 results in question.  Cauterization, in vain made trial of by M. Earle,
 succeeded in the hands of M. McDowel,  M. Baravero, M. Bellini
 (Journ. des Prog., t. V., p. 248) and of M. Taillefer, (Bull, de VAcad.
 Roy. de Med., 1.1., r.  583,) which  latter at the same time  made use
 of the erigne to approximate the borders of the wound.

                             § VII.

  Tne method the most ancient and the only one which Boyer treats
 of, is the one which  was improved  by  Desault.    It consists  in
 arranging a catheter permanently in the bladder, at the same  time
 that we keep up in the vagina a cylinder of linen, lint, or what is
 better, of gum-elastic, in order to make moderate tension  upon the
 angles of the fistula.   Desault and Chopart, who were a long time
 embarrassed with the difficulty of keeping this sound immovable, at
 last discovered a means of doing so : in  place of a double T bandage
 to which were attached the threads fastened on the extremity of the
 instrument, and  in place of tying those threads to the hairs of the 
VESICO-VAGINAL FISTULAS.
529
vulva, these authors contrived a sort of truss, the pelote of which
reaches to the mons veneris, and which has at this place a metallic
plate  curved into an arc, which is made to descend at pleasure on
the front part of the pudendum, and which is opened at its extremity
to receive  the  catheter.   This however is an apparatus much too
complicated, and does not appear in fact to possess much more secu-
rity or advantage than the one in  linen, made use of by other practi-
tioners.  Desault and Chopart maintain that they have cured several
women by adopting  this method, and even  furnish a particular ex-
ample of it.  In this example, however, they leave us in a certain
degree  of doubt, in  saying that  the woman appears  to be  cured,
and not positively that she is cured.  Moreover, since we are some-
times obliged to wait months and  even years to  obtain  a perfect
cure  by means of this  method, is it not probable that the fistula in
such cases disappears spontaneously ?  If however, we should decide
upon  employing permanent catheters, it would appear at least that
we ought to reject the foreign body, which is placed in the vagina,
according to the process of Desault.  This, by dilating the passage,
must  necessarily present an obstacle to the contraction of the fistula.

                 § VIII.—Anaplastic  Processes.

   Some modern surgeons, persuaded  that the suture and cauteri-
zation must necessarily fail in the  great majority of cases, have in
seeking for another remedy for vesico-vaginal fistulas, proposed the
method of  anaplasty.   I have  stated in the first volume of this work,
what  anaplasty has effected in this respect, by the transportation of a
cutaneous  plug, or by the  Indian method, or that of raising up an
arcade from the vagina, or by direct agglutination, and by means of
incisions at a certain distance; but I have said nothing of the method
of obliterating the vagina, proposed and practised by M. A. Vidal.

                 § IX.—Obturation of the Vulva.

   M.  Vidal, despairing of  success by the  methods in use, proposed
to abrade  cautiously the vulval contour of the vagina, and to unite
the wound by suture, with  the view of completely closing up the en-
trance of this passage.   The patient whom he treated in this manner,
at the venereal hospital, appeared at first to be doing very well; but
in consequence either of the  imprudence of a pupil who introduced
the catheter awkwardly, or by the action of the bladder itself on the
urine, the  agglutination was not maintained.   M. Vidal, in a second
attempt at the Hospital of Necker, did not procure more satisfactory
results.  The principle of this method, moreover, requires to be far-
ther investigated.  The catamenia would be obliged to pass through
the bladder, by means  of  the fistula, in  order to make  their exit
through the urethra.   Hence arises a serious inconvenience for those
women  who have not yet passed  the period of life when the menses
cease.  This obliteration, moreover, as it presents an insurmountable
obstacle to procreation, can scarcely be thought of in those who have
not arrived at that age  at which  the genital functions  have ceased,
except as  a dernier resource.  The urine, by being obliged, before
  vol. in.                    67 
530          NEW ELEMENTS OF OPERATIVE SURGERY.
making its escape, to fall into and to  stagnate in the vagina in the
same wav as if it were a second bladder, would  almost unavoidably
deposite there saline matters and lithic concretions, which would  soon
constitute a real disease.  I could not then approve of the method of
M. Vidal until after having in vain made trial of all the others.   It is
to be apprehended, moreover, that it would  not be found much more
easvto  close up hermetically  the  vulval opening of the vagina  than
the"vesico-vaginal fistula itself.   The  two trials of M. A idal furnish
already a proof of this.  A woman, who in consequence of  pain-
ful labor had the vesico-vaginal septum ruptured, suffered so much
at the vulva that the  entrance of the vagina was reduced by degrees
to a  simple aperture.  When  she came to the chnique we could rea-
dily  ascertain, by introducing  the catheter into the bladder, the exist-
ence of a large opening in the  vesico-vaginal septum, while the ex-
terior aperture of the vagina  was not  more than  half a line in diam-
eter.  Before acceding  to  the  desire of this  woman, who wished
above all things to get rid of the vulval  occlusion,  I  endeavored
under various pretexts to close the small orifice mentioned, by means
of cauterizations either by the  nitrate of silver  or nitrate acid of
mercury, and even by the hot iron, and on one occasion by the aid of
the suture, after having abraded the parts ; and  I must  confess that
it proved impossible for me  to succeed.  It must be added moreover,
that  since the accouchement of the patient, who was about  40 years
of age,  and which had taken  place nearly two years before, she had
no longer menstruated, and  that consequently we were not enabled
to ascertain the obstructions interposed to the flow of the catamenia
after the obliteration  of the vagina, by the method of M. Vidal.

                   § X.—General appreciation.

  I have now an "unpleasant duty to fulfil, in stating that among the
cases related of cures of vesico-vaginal fistulas, there are but a very
small number which are entirely free from all  contestation.   It is
certain, as M.  Jeanselme has showr, (VExperience, t. I., pp. 257,
270,) in a detailed memoir on this subject, that the cases attributed
to Desault by Chopart, to Flamand by M. Erhmann or M. Deyber,
and  to Dupuytren by MM.  Sanson and Paillard,  and those ascribed
to M.  Ncegele, M. Malagodi, and M.  Jobert, and  several of those
which belong to M. Lallemand, are far from being conclusive.
  A. To understand ourselves on this subject, and to enable science
to advance in a proper manner, it is necessary to divide urinary fis-
tulas in women into three classes.  Those which cause a communi-
cation between the urethra and the vagina, may be treated success-
fully by cauterization or the suture.  There is every reason  to be-
lieve also that a certain number may be cured by adopting the pre-
caution of catheterizing the woman whenever she  is under the ne-
cessity  of urinating,  and by not allowing her to  evacuate her blad-
der  herself.  I have  succeeded in this manner in one instance.  In
another woman whom I operated upon in  1838 at La Charite, I con-
fined myself to  the extirpation of the urethral bridle, which separated
the  fistula from the  meatus urinarius.   As the neck of the bladder
was not  implicated, this  small  operation was attended with entire 
VESICO-VAGINAL FISTULAS.
531
success, and the urine could afterwards be evacuted in the same way
as before the disease.  The fistulas which are situated  at  the  neck
of the bladder or root of the urethra, in other words,  those which
are established at the expense of the trigonus vesicalis, appear also
to be susceptible of a radical cure.   Nor do  I  doubt that  many of -,
those patients treated by MM. Lallemand and Jobert,  were of this
description.  There is also every reason  to  believe that  the cures
attributed to Dupuytren and others, belonged to this class of fistulas.
It was probably from having overlooked this  distinction, that several
practitioners have felt themselves aggrieved by the doubts which M.
Jeanselme in his memoir has  expressed  in relation  to  their cases.
As to the fistulas of the body of the  bladder,  there is  no fact  up  to
the  present  time, which proves indisputably that  they have  been
cured.  It is true that  Levret and Deleurye state, that the depression
of the uterus and its neck will succeed in such cases; but we find by
the  case  of M.  Horner, (Gaz. 3Ied., 1838, p. 124,) that tractions
made  upon the  neck  of the womb by means of an ephelcometre,
have proved insufficient for  the  cure of those fistulas  which  have
been hitherto treated by this process.
   B. It is to be recollected, moreover, that fistulas of the body and
the bas fond of the  bladder, present numerous varieties.   In many
women whom  I  have seen, the vesico-vaginal septum was so  com-
pletely destroyed, that the  bladder and vagina no longer constituted
anything more than one and the same  cavity, that the anterior wall
of the bladder, from being  no longer supported, descended down  as
far as the vulva,  under the  appearance of a reddish-colored  fungus,
so that it would have been  absurd to have thought of curing an infir-
mity of this description in  any other manner than by the method of
M. Vidal.  I have had an  opportunity of examining two women in
whom the fistula was so  high up that its  superior border was repre-
sented by the anterior  side  of the neck of the uterus.   Is it not evi-
dent that cauterization or abrasion, combined with depression of the
uterus, might  in  these  cases have presented some prospect  of suc-
cess ?  In another woman, the fistula, which  was at the bas fond of
the bladder, and of a circular  form, was situated in  such manner ex-
ternal to the mesian line, that it could be closed up quite entirely by
means of slight pressure  made through the vagina.
  C. For the future, therefore, it will be  advisable not  to cite cures
of vesico-vaginal fistulas, without actually defining their  precise seat,
form, and dimensions.  This, it would appear, is what is required by
M. Jeanselme, and I consider  that an  advantage would be derived
from it in practice.  In conclusion,  however, I would  remark, that
uretro-vaginal  fistulas  yield without any great difficulty to  the re-
sources of art or the salutary efforts  of nature; that those  of the
trigonus-vesicalis rarely disappear when they have more than eight
to ten lines diameter; that those that are the  highest up in the vagi-
na also do not appear to be absolutely incurable ;  but that in  regard
to those of the bas fond,  I  feel myself compelled, without  being  as
wholly incredulous on this subject as M. Jeanselme, to avow, notwith-
standing, that there is reason to call in  question almost every one of
their alleged cures which hi >* teen published up to the present time. 
532
NEW. ELEMENTS OF OPERATIVE SURGERY.
                   §  XI.—Palliative Treatment,

   Where the case is incurable, an oval ball of gum-elastic is one of the
best remedies to make use of.  The means then to be used are no longer
designed for any other purpose than that of cleanliness, and to protect
the organs against the acridity of the urine, or  to receive this liquid,
in such manner that  the patient may be incommoded by it as little
as possible.  For this purpose J.  L. Petit had an instrument con-
structed  which he  called  the trou d'enfer, and which, according to
him, fulfilled the intention perfectly;  but  as he has not described
it, we have not  been  enabled  to derive  any advantage  from it
since; fortunately  that of Feburier,  and which  is met with  in
most of  the  gum-elastic instrument-shops,  leaves nothing to desire
on this  subject;  it is a sort of cup made of caoutchouc, which
may be kept in front of the vulva,  and  prolonged into  the vagina
without preventing the woman  from walking  or  attending to her
usual occupations.   M. Barnes, who in consequence of the frequency
of vesico-vaginal fistulas among English women, has been frequently
obliged to direct his attention to this subject, makes use of an elonga-
ted gum-elastic bottle, which can be  adjusted in  the vagina, and
which has on its anterior face an opening in which a sponge is intro-
duced and applied to the fistula in order that the urine may gradually
pass  into it.   The patient withdraws  the whole  two or three times a
day,  expels the urine by simple pressure, which, acting on the sponge,
empties the instrument completely.  M. Guillon and Duges have each
contrived  an instrument which  may  be considered  as  an improve-
ment of  that of Barnes.   Finally, if none of  these means are at
command, the only resource which the woman would have would be,
to make  use of portions of fine sponge, dry linen  and  silk paper,
which would have to  be renewed a greater or less number of times
daily.  The semiflexed position on the belly, as recommended by M.
Cha'illy, (Transact. Mid., t.  VI., pp. 283,  293,) with the view of
forcing the  urine to  escape  by  the  urethra, with  the catheter or
aspirating syphon  which was  to be introduced to prevent the urine
from passing through the  fistula, has in the  first place  the incon-
venience of not effecting its object.  In the next place it  is impossi-
ble for most women to keep it up over a day or two.  M.  Schraeger
and  M.  Sanson, who  made use  of this process a long time since,
derived no benefit from it and were soon deterred from its employ-
ment by the sufferings and the sores that it was calculated  to  pro-
duce upon the knees, elbows and  spines of the ilium.
  [Vesico-Vaginal Fistulas.—M. Berthe of Gay, (Arch. Gen , Aoftt
1844, p. 511,) states that he has cured  three fistulas of this descrip-
tion  by cauterizing, with the cautery at a white heat, which  he was
enabled to accomplish  effectually by making  the borders of the fissure
project freely into the  vagina, by keeping the bladder constantly dis-
tended with air during the operation.
  Even the great destruction of the vesico-vaginal septum from diffi-
cult  labor, did not, m  our opinion, justify the severe operation of M
A B,rard(Arch.  Gen.. Sept.,  1845, p.  77, &c.)  in attempting to
alleviate  the  difficulties  by dissecting a circular mucous  diaphragm
or flap behind the  nymphae, drawing that backwards and then bring- 
RECTO-VAGINAL FISTULAS.
533
 ing the abraded surfaces, both of the flap and of the parts from which
 it was removed, into coaptation, (the latter by the quilled suture,) so
 as to obliterate the vagina both in front and  behind  by a species of
 infibulation.  Death followed as a matter of course.
   In regard to the obliteration  of the vagina as a remedy to the dis-
 tressing annoyance from the urine in cases of extensive vesico-vagi-
 nal  fistulas, M. Velpeau, like  most  other surgeons  of experience,
 disapproves of this  operation,  which has been  attempted  by  MM.
 Vidal, A. Berard, &c., but now contends (Arch. Gen., 4e ser., t. VII.,
 Mars, 1845, pp. 370, 371) that  it is not so alarming  as some think,
 and that the  objection  raised on account  of the obstruction to  the
 escape of the catamenia through the small aperture left, is unfounded,
 inasmuch as the menstrual fluid, from not being coagulable, can  as
 readily  flow  through  this aperture  as the urine does.  See  text
 above   T.]

            Article XII.—Recto-Vaginal  Fistulas.

   The posterior wall of the vagina, like the anterior, is exposed to
 the risk  of  being lacerated during parturition, cf being contused by
 the head of the foetus and branches of the forceps, and of being perfo-
 rated by abscesses, gangrene, &c.  A young woman at the Hospital
 of La Charite, who was completely destitute of a recto-vaginal septum,
 insisted that the perforation was produced during coition, and I have
 had  communicated to me a similar fact; but I am induced to believe
 that the infirmity in these cases has been congenital, and that  the
 women under  such circumstances have been desirous of concealing it.
 This species of fissure or fistula, however, without being exceedingly
 rare, has not been as frequently observed as vesico-vaginal fistulas;
 without doubt because the friction made behind the pubes by  the
 head of the  infant, and the instruments which accoucheurs are some-
 times obliged  to make use of, compress the bladder  with more vio-
 lence, upon  a more circumscribed and more projecting and irregular
 point of bone than they do on the rectum behind.

                    § I.—Spontaneous Cure.

   From  recto-vaginal fistulas being  somewhat  more  inclined to a
 spontaneous cure  than those of  the vesico-vaginal  septum, it has
 very naturally happened  that they have been generally overlooked.
 Ruysch had already mentioned the  case  of a woman who had an
 opening in the recto-vaginal septum of  an inch in diameter,  but who
got well without an operation.  M. Philippe  of Mortagne (Arch. Gen.
de Med., t.  XXIII.,  p. 568) noticed  in 1829  a case  nearly similar.
 The  patient  whom he mentions  had an  enormous perforation, which
made a communication between the  rectum and vagina.  The most
celebrated surgeons  of the capital were consulted, and all  of them
gave it as  their opinion that the disease  would probably remain
incurable, and  that they saw no operation that could  be undertaken.
Means for cleanliness, together with a position upon the side, consti-
tuted the whole treatment made use of  by M.  Philippe.  After
having become considerably enlarged, the fistula began to contract,
bo much so that after the expiration of a few months  it was found to 
534
NEW ELEMENTS OF OPERATIVE  SURGERY.
be completely closed.  At the time the case was published the cure
continued perfect  and there was no reason to apprehend  a  return.
Analogous cases have been related by Fichet de Flechy, M. Capu-
ron and  M. Deschamps.  Sedillot (Journ. Gen. de Med., t. 56)  had
already published a case nearly similar; it differs from it only in this,
that the  disease belonged  to that description  which Smellie  had in
vain endeavored to cure, but which Noel overcame by means of the
twisted suture.   Unfortunately the system does not always co-operate
so kindly with the wishes of "the practitioner, and it is  but  too com-
mon to find that lacerations of the recto-vaginal septum persist not-
withstanding the best directed efforts.  All the means  proposed for
vesico-vaginal fistulas are  equally applicable to this.

                              § II.

  Cauterization, for example,  seems  calculated to  succeed  fre-
quently.   It is, in  fact, ascertained  that by abrading the angle of a
fistula  of this description, by  any mode whatever,  adhesion  rarely
fails to take place, at least to the extent of a few lines.  In using the
nitrate of silver by this process, it would  be  required to cauterize
only at each time the most remote portion or  commissure  of  the
fistula.  It is nevertheless true that these fistulas do not readily yield,
unless  they are  very small, and that therefore it would be useless
undoubtedly to attempt a trial  with  caustics when they are of large
dimensions.   A more efficacious resource probably  would  be found
in the erigne forceps ofM. Laugier.  Injections ofred wine effected
a cure in one instance, in what manner I do not know, in the space
of fifteen days, in a young woman who came into my department at
La Pitie, and in  whom the fistula had existed  for the space of eight
months.
                         §  III.—Suture.

  The operation which at first sight would appear to present  the
greatest degree of certainty, is the suture.  Only that it is an unfor
tunate circumstance that it is so difficult of application  that we can-
not, up to the present time, enumerate but  a very small number of
cases in its favor.  Gardien states that it was unsuccessfully attempt-
ed by A. Dubois, and Boyer considers that if all the failures by this
process had been  published, there would at  the present day be a
great number made known.   It has nevertheless Succeeded  and as
it is probable that  by improving  it we may ultimately derive more
benefit from it, I consider that it is worthv of further trials    The
first cure which  was effected by this process,  was in  the case pub-
lished  by Saucerotte, (Recueil Period,  de la  Soc. de Med  t  IV)
The patient had at the same time a perforation of'the recto-vaginal
septum above the sphincter, and a laceration of the perineum in front
of the anus   The  surgeon caused the vagina to be dilated by  means
of a speculum with two branches,  and  introduced into the rectum
through the anus,  a sort of wooden gorget, the  convexity of which
was placed underneath the fistula, to serve as  a  point d'appui to the
other instruments.   The opening being thus  exposed to view Sau
cerotte exsected its  borders, one half  by means of a  bistoury pro 
RECTO-VAGINAL FISTULAS.
535
tected by a bandage, and the other half by a species of cutting rasp.
The glover's suture, which he gave the preference to, was applied by
means of two  curved needles, one which was shorter to begin th
operation, and  the other longer to  terminate  it.   The forceps ana
usual needle-holder had been slightly modified for this purpose, that
is to say, that their  extremity was arranged  in  such manner that
the needle could be fastened  in  them in any direction.  Saucerotte
then introduced, by means of this instrument, his first point of suture
as far as to the upper angle of the abraded fistula, where he secured
his ligature by means of a portion of adhesive plaster, in  order that
he might dispense with knotting it.  He afterwards made with the
other needle six turns  of spiral or whip  suture, proceeding from be-
hind forwards,  and secured it ultimately by knotting the two  halves
of his ligature  upon  a foreign body.  For  several days there was
reason  to  believe that the cure  would  take place, but the woman,
who had not had a stool during the time, was  then obliged to make
use of so much effort to evacuate the hard and lumpy foecal matters,
that the suture  was thereby torn  out, by which the greater  portion
of these matters escaped through the vagina.  Saucerotte, however,
finding that the adhesion maintained itself in the upper portion of the
fistula, and that the woman herself desired the operation to  be re-
peated, made another trial at the expiration  of a month.  This time
he took the precaution to divide the bridle  formed by the sphincter,
in order that there might be no obstacle to  the free passage of the
matters ; the case was completely successful.  A similar success, it'is
said, was since  obtained by M. PI. Portal, (Gaz. Alid., 1835, p. 696,)
in a young girl  four years of age.  But a woman who had been al-
ready operated upon in this manner unsuccessfully at Clermont, was
not more fortunate in the second trial  under the hands of M. Roux,
(Mercier, Journ. des  Conn.  Med.-Chir., Mars, 1839, p. 97.)  Noel
(Rec de la Soc de Med., &c, t. VII., p. 187) also made use of the
suture in a case very similar to that of Saucerotte.   The woman had
the entire perineum and the  anus, and a portion of the septum, rup-
tured during a protracted labor.  He had recourse to the scissors to
abrade the two lips of this ancient fissure; inserted several needles,
one on a line with the sphincter, and also another at an inch above;
secured them by means of threads, as in the twisted suture; kept the
thighs together by some turns of bandage which embraced  both
limbs; and enjoined upon her to keep upon her back, in order to en-
able the faecal matters to escape by passing along the posterior wall
of the rectum,  and ascertained  to his satisfaction, after  having re-
moved his  second  needle, that the  reunion was perfect, not only at
this point, but also.in the entire upper portion of the wound, where,
nevertheless, the suture had not been applied, and the lips of which
had not been brought into contact, except by means of the approxima-
tion of its lower  portion. This cure, which remained permanent, proves
that Smellie, in  his case, might probably have obtained the  same re-
sult if he had proceeded more methodically.   These two facts, how-
ever, belong rather to suture  of the perineum  than to  recto-vaginal
fistulas.  In a case since published by M. J. Nicols in England, it is
perceived that the operator was obliged to repeat the suture three 
536
NEW ELEMENTS OF OPERATIVE  SURGERY.
times.   But his exertions were  ultimately crowned with complete
success.
                             § IV.

  Anaplasty should be as applicable to recto-vaginal as to vesico-
vaginal fistulas.  I failed in it however  in one  instance, in trans-
porting a plug borrowed  from the vulva, (see Vol. I.,) and I was not
more fortunate in another woman, in compressing with an elastic for-
ceps the two walls of the fistula, the track  of which ran obliquely
through the tissues of the recto-vaginal septum.

           Article  XIII.—Entero-Vaginal  Fistulas.

  Other fistulas, as those denominated entero-vaginal, have also at-
tracted the attention of surgeons.   A noose of  small intestine, or the
sigmoid flexure of the colon when it has protruded into the recto-
uterine cavity, may  on being perforated, show itself outwards pos-
terior to and above the vagina, as has been seen by M. Roux, (Arch.
Gen. de 3Iid., t. XVIL, p. 300,) and also by M. Caza-Mayor, (Journ.
Hebd.,  t. IV., p.  174.)   Two very different kinds of operations,  both
in their processes and in their results, have been devised as a remedy
for this description of accident, which, when it  happens, constitutes a
sort of artificial anus.   The  patient of M. Roux, a  young woman
whose  fistula had existed  for the space of several years, having been
admitted into La Charite, was anxious at every hazard to be relieved
of her disease. The surgeon considered that he might effect the cure by
opening upon the intestines through the abdominal walls.  His inten-
tion was to invaginate the termination of the ileum, after it had been
previously detached from the vagina, into the lower end of the large in-
testine, and in this manner to re-establish the continuity of the alimen-
tary canal, by means of the suture, according to its modified applica-
tion in these latter times.  This bold attempt was followed by the most
disastrous consequences.  The  patient  died, and it was  found on
opening the dead body, that the gut which should  have been placed
downwards, had been placed in an opposite direction.   The process
adopted by M. Caza-Mayor, in his case, though more rational in ap-
pearance, and less dangerous, did not nevertheless succeed perfectly,
the patient  having been suddenly carried off by a  pneumonia.   The
instrument used by this surgeon, is constructed upon the same princi-
ple as the enterotome  of  Dupuytren.  It  is a kind of forceps, each
branch of which is terminated by an oval plate eight lines lone, and
four lines broad, and having some teeth on its side  towards the°intes-
tine.  Being introduced, one branch through the vagina and  fistula
as far down as to the perforated gut, and the other through the rectum
so as to meet the first, the object of these plates is to approximate and
to place in contact the corresponding walls of the two portions of the
alimentary  tube, to destroy  immediately the septum which results
from this  adossement, and to produce in this  part a  loss of  sub-
stance.   The forceps in its  whole extent was 8 inches long; its
branches, which were articulated like a common forceps, left between
them a sufficient space to include the entero-vaginal septum and the
perineum ;  while a quick screw which perforated their outer extrem- 
              FISSURES AND SUTURE OF  THE PERINEUM.          537

ity allowed of their action being regulated at pleasure.   The results
took  place as  the operator had anticipated;  the stercoral matters
partially resumed their natural course, and everything led to the be-
lief that the fistula in the vagina would have speedily closed, when the
woman died, a victim to her indiscretion.   It may, in fact, be readily
conceived, that when an artificial perforation takes place in the rec-
tum,  the  foecal matters  might  partially escape  through  it; but in
regard to a primitive fistula, how can it become obliterated and cease
to receive these matters 1

     Article XIV.—Fissures and Suture of the  Perineum.

   The protrusion of a large sized polypus, or parturition, may some-
times involve among their  consequences  such extensive lacerations
of the perineum as to require  the aid of operative surgery.  If, as I
have  seen in  many instances,  these fissures  should be made trans-
versely, or include  the  fourchette only, they require no attention.
Nature herself will effect their cure, or  they leave a deformity of too
trivial a character to demand  the notice of the surgeon.  Fissures in
the posterior  commissure of the vulva  on the contrary, and which
extend to the neighborhood of the anus, and with  still greater reason
those which include the sphincter of this opening in such manner as to
unite the rectum with the vagina, claim all the attention of the opera-
tor.   If the extremity of the recto-vaginal septum participates in the
fissure, the stercoral matters which frequently then can no longer be
retained,  actually constitute the vagina  into a species of cloaca, and
place the woman in  the same situation as those afflicted with artificial
anus.  From the absence of the perineum, the uterus has a constant
tendency  to descend, and it is found almost impossible to support  it
by means of pessaries.   Impregnation,  on this account, is attended
with greater difficulties.   Parturition itself is scarcely rendered more
ejtsy by this circumstance, for it is the osseous strait, and not the pe-
rineum, which may oppose an obstacle to  the passage of the head of
the infant.   These lacerations have been  observed at every epoch.
If they have been in most cases abandoned to the resources of the
system, this is  because their spontaneous  cure, whether complete or
incomplete, has not  been  a very rare occurrence, and perhaps also
because the surgical means which have  been used up to these latter
times did not possess any great  degree  of efficacy.

                     § I.—Spontaneous Cure.

  Thymoeus  had already mentioned that a woman who  had her
perineum  completely lacerated, had recovered  without any kind
of treatment.   Peu affirms that  a patient  whose perineum  was rup-
tured  to such extent as to render her incapable of  retaining her stools
or the injections, was nevertheless perfectly re-established ; but it is
proper to add that De la  Motte, who alleges that he saw this woman
thirty years afterwards in Normandy, maintains that  she was not at
all cured.   Mauriceau, in speaking of the  suture,  confines himself to
recommending to women that they should no longer bear any chil-
dren.   Deleurye  says positively that these large  solutions  of conti-
   vol. m.                     68 
538           NEW  ELEMENTS  OF OPERATIVE SURGERY.

nuity do not require the suture.  A perineum lacerated as far as the
anus is, says  Puzos, an unfortunate accident;  but by keeping the
limbs together by means of a bandage, women may, he says, be cured
full as well as by the  suture.   Aitken considers that the  suture is
never admissible in  such cases.  In this he is supported by  M. d'Ou-
trepont and some other modern accoucheurs.  A cure it is said was
obtained by this process in one instance by Trainel, (Journ. Gen. de
Aled., t. IV., p. 427.)   It would be going too far, therefore, to  say
with M. Roux, that no one has ever seen reunion effected in these
cases by the efforts  of  nature alone.  This reunion was so  complete
in a case related by Trinchinetti, that it subsequently became neces-
sary to incise and dilate the entrance to the vagina to allow of copu-
lation.
                              §11.

   The suture, nevertheless, which  has frequently been made trial of
unsuccessfully, and  again in our time by A. Dubois, and  by M. Paul
Dubois in  two different cases, and afterwards by another practitioner
quoted  by M. Blundell, has often  succeeded.  Guillemeau,  who had
to treat in this manner a laceration prolonged  as far as to  the anus,
made use  of one point of twisted suture  and cured  his patient in
fifteen days.  De la  Motte, who considers the suture infallible, placed
three points in one case, one on the recto-vaginal septum, one on the
perineum  near the  anus, and  the other in the  neighborhood of the
fourchette, and succeeded without any difficulty.   M. Morlanne, by
proceeding in the same manner, was no  less fortunate in  a similar
case.   The same was the  case with  M. Montain the  younger, who
had  recourse  to the quilled suture;  with Osiander, who cured his
patient with the simple suture ; with Dupuytren, whose case was not
published  until the  year 1832; with M. Rowley, Mursina,  Mentzel,
(Roux, Restaur, du  Perin., p. 12—Institut. Sav. Etrang., t. V.,) and
M. Dieffenbach; so that, including the case in the Ephemerides Cu»
riosorum Naturae, science  already possessed at  least  ten  examples
without adding those  which  M. Meissner attributes to Churchill,
Alcock, and Zang, before  M. Roux again drew attention to this  sub-
ject.  M.  Busche extols especially the method  of M. Dieffenbach,
who, together with the simple suture, made a long arched incision on
each side of the laceration.  A rupture of the recto-vaginal septum
was cured by  Laugier  by  means of a simple suture, as  in the case of
Saucerotte, which last gave the preference to the glover's suture.
Without considering the twisted suture indispensable, I am, never-
theless, of opinion that this is the one that deserves the preference in
every case where there is no special indication to  the contrary.  This
is the one  that M. Roux has made use of in all  his patients, while in
the only case in which this practitioner employed the twisted suture
he failed (Restaur, du  Perin. &c, p. 16.)  He counts at the present
day thirteen cases.  It must be remarked, however,- that two of his
patients died, in one of which  (Ibid., p. 36,) there was only a partial
rupture, while  the other, on the contrary, (Ibid., p. 27,) was placed
under very unfavorable circumstances.   M. Roux, who imputes the
rupture of the perineum in this last woman to an  operation for fistula
in ano, allowed himself to be imposed upon by false statements of the 
FISSURES AND SUTURE OF THE PERINEUM.
539
 case.   It was in  my  department at La Pitie where  this case had
 been received, and while there she appeared to me to be so exten-
 sively ravaged by ancient syphilitic ulcerations, that I confined  my-
 self to excising one of the bridles which obstructed the anus, without
 deeming it advisable  to pay any attention  to the laceration of the
 perineum.  Having rectified this error in my Treatise  on Accouche-
 ments in 1835; I  had reason to be astonished to see it repeated in
 1839  by M. Roux, (Ibid., p.  27,)  and by M. Mercier, his  pupil,
 (Journ. des Conn. Med.-Chir., Mars, 1839.)  I  will remark, more-
 over, that in two other patients  he found it necessary to repeat the
 operation. A lady of New Orleans, also, who had been unsuccessfully
 operated upon by M. Roux, had the disease return, but  was unwilling
 to undergo another trial.   Moreover, it has been performed at the
 present day  by other surgeons;  M. Convers, among others,  (Gaz.
 Mid., 1835, p. 44,) has employed it in one instance with success.  I
 myself have had recourse to it  in two cases ; one was  cured and re-
 mains  in good health; in  the  other death  was caused by a perito-
 nitis at the expiration of thirty days, though  the perineum had be-
 come  perfectly agglutinated, A patient whom M. Mercier states that
 he operated  upon, (Journ. des Conn. Med.-Chir., Mars, 1839, p. 94,)
 a short time after the accident, also died.  A  circumstance which
 is not to be overlooked is this, that after the  reunion  there remains
 quite  frequently  a  kind  of fistula  at the lower part of the recto-
 vaginal septum.  M. Roux asserts (Restaurat. du Perin., &c, p. 24,)
 that this opening continued for a long time in the wife  of the surgeon
 of Vaiogne.   It also continued open, (Ibid., p. 31,) he says, in another
 patient, after which  he saw no more  of her.  M. Roux, in assert-
 ing that this opening has, in almost every instance,  ultimately be-
 come  obliterated,  or so narrow  (Ibid., p. 34,) that  it  no  longer ad-
 mitted  the escape of anything  but a small quantity of gas, does not
 thereby prove that it has in  reality completely closed  up.  I find, in
 fact, in the  thesis of  one of his  pupils, (Rampon,  These No. 332,
 Paris,  1837,)  that  it  quite  frequently remains  open.   I know a lady
, operated upon by  M. Roux in whom this fistula has not  diminished
 any since the year 1834.
   In conclusion, lacerations at  the vulva should  be divided into two
 classes: those which extend only to the neighborhood of the  anus,
 but  leave intact the  sphincters  and the recto-vaginal septum, consti-
 tute the first  class;  while  the  second comprises all  those ruptures
 which completely unite the  anus and  vagina, and which encroach
 more or less upon the septum.   When the accident is recent, what-
 ever may be the species of rupture, it is not proper to  have recourse
 to a surgical operation; we must then  confine ourselves  to the ap-
 proximation of the thighs, and  to  repose, and  also to the keeping of
 the bowels open and to various means of cleanliness.   The tumefac-
 tion and congested state of the  parts, would not allow of the suture
 succeeding under such circumstances.   I once had recourse to it in a
 case of this kind and it failed completely.  If, at the termination of a
 month or two, the  rupture has not reunited, nothing more is to be ex-
 pected from  the efforts of the  system; but we  must wait until the
 woman  has recovered her strength, and until the lips of the wound
 have cicatrized separately.  We have then  to ask  ourselves the
• 
 540           NEW ELEMENTS OF OPERATIVE SURGERY.

 question, which  is the preferable kind of suture.  It is certain that
 the simple  suture would  succeed in a very considerable  number  of
 cases, even where there was a rupture of the entire perineum.  De
 la Motte, contrary to the assertions  of M. Roux, has positively used
 this suture  with  entire success.  I have already said that it was no
 less efficacious in  the  hands of  M. Morlanne.  Nevertheless, if the
 simple or twisted suture in reality answers in cases of partial rupture,
 as is proved, moreover, by the numerous  examples of episiography
 published by M.  Fricke, and by my own cases, it is also certain that
 where the  rupture is complete  this  suture, in many cases, will  be
 found to be uncertain or insufficient.
   A.  Partial ruptures.—Those  fissures of the perineum, which stop
 in front  of  the anus without including the recto-vaginal  septum, do
 not disturb the functions  of the rectum, mat  they favor  the  descent
 of the uterus, and may be attended with unpleasant consequences in
 respect  to the conjugal relations  and duties.  It  is allowable, there-
 fore, to  undertake their cure when this is desired by the woman.   In
 these cases the twisted suture, or better still, the simple interrupted
 suture, will almost  always be found sufficient, and possesses scarcely
 less efficacy than the quilled suture.
  I.  The woman should be placed in the same way as for the  opera-
 tion for  lithotomy.   The surgeon being in front, and either seated,
standing up, or on  his knees, begins by abrading  the  borders  of the
fissure.  For this purpose he removes from it a pellicle, commencing
at the neighborhood of the anus, and proceeding to the distance of
an inch  and a half  or two inches in front.   The  excision should be
carried through the entire depth  of the fissure, from the cutaneous
tissue to the  inner  membrane of the vagina; we  should take care
also that all the points of the periphery of this fissure are completely
rawed, without excepting the lower extremity of  the  posterior co-
lumna of the vagina, which in such cases usually makes  a very con-
 siderable projection at the deep-seated border of the wound.
  II. After having wiped off the blood, which sometimes flows out in
 considerable abundance, the surgeon inserts the threads, one behind
 in the direction of  the anus, another in front towards the  nymphae,
 and the  third at the middle portion.   For this purpose, beginning al-
 most indifferently with the first or the last, he seizes and  plunges  in
 from without inwards, and with his right hand,  a  curved needle
 through the left lip of the wound, taking care to enter at from  four
 to six lines outside of the bleeding surface, and  to  come out very
 near the mucous tissue.   A good  pair of forceps, when the  fingers
 of the left  hand  are  not found  sufficient, will serve to support the
 tissues while  they are being thus perforated.   The needle is then im-
 mediately conducted with the same hand from within outwards, and
 from the bottom  of the wound, through the other lip of the  division,
 in such  manner that it may come out through the  skin at  the  same
 distance from the abraded tissues.  We proceed in the same manner
 for the  introduction of the  second and third thread.   I would how-
 ever remark, that  it would be possible, if we begin by the upper
 thread, to make traction upon its  two extremities, in order to give
 tension to and to approximate the division, so  that by placing the two
 fingers of the left hand outside of this division, as if for the purpose
• 
FISSURES  AND SUTURE OF  THE PERINEUM.
541
 of pinching up its sides, we would  be enabled by one movement  to
 introduce the needle through the entire thickness of the tissues, which
 are to be embraced by the suture.  It is also important that the mid-
 dle thread  should comprise in its noose the abraded extremity of the
 posterior columna of the vagina, at the same time that it includes the
 sides of the wound.
   III. Having arrived at this point, the operation has no longer any
 thing remarkable ; each of the  threads is knotted on one side by a
 simple knot supported by a bow, and in such  manner as to exercise
 a certain degree of constriction  on the parts.   In case the twisted su-
 ture should have been preferred, we would have nothing more to do
 than to introduce each of the needles or strong pins, with  the same
 precautions, or in the same manner as in the preceding case.  After-
 wards throwing a noose of thread round their extremities, we would
 proceed in the same manner as has been described in  treating of
 twisted suture in general, except that their points and  heads would
 have to  be afterwards carefully  protected  and  raised  up,  be-
 cause of the perineal groove where they are  obliged to  remain im-
 bedded.   As the quilled suture does not require any other rules under
 these circumstances than in the following case, it is unnecessary  to
 dwell upon it  at this time.
    IV.  Subsequent treatment.—In order that  the operation may suc-
 ceed, the woman is required  to remain for a week at least  at rest,"
 with her thighs kept together, and not to  evacuate her urine sponta-
 neously.   It is advisable also that she should not be compelled to go
 to stool, and that the perineal region, though not requiring any cover-
 ing, should be  cleansed  and  carefully washed  several times a day.
 A catheter left in the  bladder irritates  and fatigues the patient too
 much ; it is better to introduce  it every eight or six hours.  A meche
 in the anus is  only calculated to jeopardize the success of the opera-
 tion.  Nor does the one which could be introduced through the  re-
 mainder of the vulva, or through the anal angle  of the wound, into
 the interior of  the vagina, appear to me of any more utility.  Nor are
 the lateral  incisions, which are  made by M. Dieffenbach under these
 circumstances, any more indicated in these cases ; for the tissues are
 naturally so pliant that it does not become necessary to make any great
 degree of traction  upon them to bring the lips of the wound into ex-
 act coaptation.  The  reunion is usually so far advanced at the sixth
 day, that the ligatures, which are then generally loose and movable,
 may be divided and withdrawn  without any inconvenience.  Before
 doing this, however, it is well to encourage a stool by means  of one
 or two glasses  of Seidlitz water, in the same way as we should in the
 beginning have dissuaded from  any inclination of this kind by means
 of opiate preparations.  Some days more are still required to con-
solidate the agglutination of the parts, and it would be dangerous to
 allow the woman to separate  her thighs or legs entirely before the
 tenth or twelfth day.  Injections into the vagina, and lotions exter-
 nally, with emollient, detergent, or antiseptic liquids, would be advi-
 sable, during the first  days  after the operation, if purulent or other
 matters should have accumulated in quantity in the  vagina or upon
 the  perineum.
   V. Dangers.—However simple and innocent this operation may 
 542           NEW  ELEMENTS OF OPERATIVE SURGERY.

 appear to be, it nevertheless sometimes exposes to the risk of serious
 accidents.   Two ladies upon whom it was performed, were seized on
 the third day with a hemorrhage, which continued in one of them to
 the termination of the second week, and which in both  of them was
 sufficiently copious to cause repeated syncopes, and to  give me se-
 rious alarm.  Notwithstanding  which, no artery  of any importance
 had  been opened, but the blood escaped by  exhalation; but I could
 not assert that it came rather from the  bottom of the  wound, than
 from the inner surface of the vagina or uterus.  A young woman who
 was operated upon in this manner, and  who did  very well until the
 tenth day, was then attacked with obscure pains in the bottom of the
 pelvis, and soon after with a peritonitis, which ended  in death.
  B. Complete Ruptures.—It was for cases  principally in which the
 perineum was completely ruptured. thatM. Roux proposed the quilled
 suture.   This surgeon having failed  with the simple suture, in one
 instance in which he used it, supposed that this result was owing to
 the circumstance that the bottom of the  parts had  not been  kept in
 perfect contact;  from that  time, his method has not changed.  The
 woman is placed and supported  in the same manner as for the suture
 of partial divisions.   The abrasion of the parts is  effected also in the
 same way, and wTith the same precautions.  It is necessary, moreover,
 that  it should be performed  upon the anterior half of the anus,' and the
border of the recto-vaginal  septum.   The threads should  each con-
 sist of a ligature two lines broad, terminated on one end by a noose.
 The other extremity is inserted through  the eye of a  long, strong
 curved needle, with a very  sharp cutting edge.  They  are plunged
 in and brought out at 6 or 8 lines distance from  each side of the
 wound.  We must commence with the ligature that is nearest to the
 anus, so as to endeavor to comprise the  extremity  of the septum in
 its noose.   The two other ligatures are to be made to pass as near as
 possible to the mucous membrane of the vagina.   The second stage
 of the suture consists in adjusting the  supports (chevilles,) and knot-
 ting  the threads.   We pass therefore, for this purpose,  the end of a
 gum-elastic sound or bougie, which is of an exact cylindrical shape,
 into the noose of each ligature which has been left expressly for that pur-
 pose, on the left side of the  rupture.   We place another on the oppo-
 site  side, between the two separated halves of each of the same
 threads, in order that by means of a simple  knot, the  two  cylinders
 may be approximated together, while they  compress in  a uniform
 manner the bottom of the  two  sides of the  division  throughout its
 whole length.  These last knots being each fastened by  a bow, com-
 plete the quilled suture.  In order to  remedy the  swelling and sepa-
 ration even of the lips of the fissure on that portion of the integuments
 which is not supported, we  pass around  the cylinders, and in the in-
 terval of each point of suture, another thread, the two halves of which
 are to be crossed in front of the wound before knotting  them on one"
 of its sides.  We have in this manner all the advantages of the sim-
 ple  with those of the quilled suture.  The needles made use of by
 M.  Roux, from being uniformly curved into half circles, do not pene-
 trate the tissues without difficulty, and are not of  very easy applica-
 tion.  31. Vidal, in  fact, has devised  others  which are much more
 convenient; they  are merely common needles, almost straight,  with 
FISSURES  AND SUTURE  OF THE PERINEUM.
543
an eye near the point to receive the ligature.  After having inserted
them as I have said  above, through the left lip of the wound, he dis-
engages the thread from the eye, and withdraws the needle ;  then
inserted from without inwards, through the right lip, this needle again
arrives into the bottom of the wound, to be armed there with the lig-
ature, which it brings out in returning from it.  The rest of the suture
has nothing further of a particular character.  As to myself, having
made use of  ordinary suture needles of some strength, 1 have found
their application so convenient that I have had no occasion  to think of
making trial  of others.  It would appear to me, however, that for
penetrating a considerable thickness  of  tissues,  M. Vidal's  needle
would possess some  advantages over those of M.  Roux.   In what-
ever way the quilled suture has been applied for complete ruptures of
the  perineum,  it requires  precisely  the  same  precautions as those
which I have described above.  It is better in all cases to encourage
a few stools by means of a laxative rather than by injections, and on
the day before  dividing the threads rather than immediately after.

                    § III.—Process of Montain.

   M. Montain, (Therap. Med.-Chir., p.  46, 1836,) notwithstanding
the success he  obtained in his first trial  with the suture, has since
treated ruptures of the perineum by another process.  He makes use
for this purpose of a long clasp, the two branches of which are  each
armed with points which are  to perforate respectively the previously
abraded lips  of the division, and are afterwards approximated with all
the force or moderation that may be required, by means  of a trans-
verse screw.  But this clasp, which could only be accurately applied
to fissures of the recto-vaginal septum, would soon become insupport-
able, even  in such cases in the  greater number of women.  There
is no probability therefore of its being retained in  practice.

                     § IV.—Cauterization.

  Some surgeons, and M. J.  Cloquet among others, with a view of
avoiding anything like a bloody operation, have treated ruptures of
the perineum by cauterization, as I recommended in 1832, and as
Sedillot had  already done; by applying  a small  cautery heated  to
a white heat, or a crayon  of nitrate of silver, or a pencil wet  with
nitrate acid of  mercury into  the  deepest angle of the division, and
repeating this at least once a week, I supposed that the fissure would
be gradually closed from  its upper part toward the integuments.
Though cures have  been related in support of this practice, I  fear
that there has been some delusion in regard to it.  The recto-vaginal
septum treated in this manner is depressed  and becomes hardened
and  approximated to the skin, but the rupture of the perineum itself
does not approximate, nor fill up, nor close; so that we diminish the
deformity without destroying  it.

                              § V.
  After the cure of ruptures of the perineum, it may happen  that
the vulva will be found  to  be too narrow, as  in  the  young  female 
544           NEW ELEMENTS OF OPERATIVE SURGERY.
                    •
who after her delivery, while she was unmarried, was operated upon
by Dupuytren, (Gaz. Med., 1832, p. 685—Pigne, transl. of Chelius.
t.' I., p. 262,) and afterwards appeared to have a hymen which pre-
sented a resisting obstacle too much for her husband !  In such cases,
graduated dilatations and emollient ointments will almost always be
found sufficient to enlarge the opening.  We should not consequently
have recourse to the scissors or bistoury unless there was an extreme
degree of contraction.
                             § VI.

  To divide the  sphincter behind, as proposed by M. Mercier, (Jour.
des Conn. Aled.-Chir., March, 1839,) with  the view of relaxing the
parts and giving greater facility to the  stools, and of avoiding all
kind of  traction upon  the suture, is a mode which might  also be at-
tempted in serious cases.

      Article XV.—Dystochia, (Difficult  Parturition.)

  The  operations which are sometimes required for the  extraction
of the foetus having been made the subject of special investigation,
can only be  properly treated of in obstetrical works.  It would be
out of place, therefore, here to go into all the details required.  Some
of them, however, ought not to be entirely omitted.   I proceed to
give a brief account of their manual.

                      § I.—Symphysiotomy.

  Some moderns, on the  strength of a vulgar tradition mentioned
by Riolan and Pare, and which  has given rise to an opinion among
the people that in different countries the pubes are ruptured in female
infants at the time of their birth, in order that parturition afterwards
may be  rendered more easy, have supposed that symphysiotomy was
practised at the remotest antiquity.  It is true that De Lacourvee, who
wrote in 1655, makes mention of a woman who died before being
delivered, and in the dead body of whom he divided the  symphysis
pubis, with a view of enlarging the pelvis ; also that Plenk proceeded
in the same  manner,  in 1766, on another subject.  But it is never-
theless certain, that no one had  formally thought of proposing this
operation on woman  during life until Sigault, who was yet a pupil,
made it the subject of a memoir which he read in 1768 to the Acad-
emy of Surgery.  It is the only certain means which we can  have
recourse to,  to save the infant:  1. When the head is closely wedged
in the upper strait or below it; 2. When the head has passed through
the abdominal strait and has become arrested by the narrowness of
the perineal circle ;  3. When, after the trunk is  delivered, the head
is found retained in the cavity.   In such cases it is preferable to the
Cesarean operation, even after the death of the woman,  because it
would  be next to impossible to extract the foetus alive through the
walls of the abdomen.
  A. Ordinary Process.—The patient being placed upon an operating
table or upon a bed, in the same way as for introducing the forceps,
with her  lower  limbs  slightly flexed and properly separated apart' 
DYSTOCHIA.
545
is to have her shoulders supported by an assistant; two others take
charge of her knees ;  a fourth stretches the integuments of the abdo-
men ;  and to the fifth is assigned the duty of handing to the operator
the instruments he may require.  The  surgeon, seated or standing
up, to the right or between the legs  of the woman, makes with the
convex bistoury an incision which should commence a little above
the symphysis and be prolonged to the  upper  part of the clitoris.
This incision, which  comprises the  skin,  which has been previously
shaved, and all the soft parts of  the mons veneris, will be parallel to
the  axis  of the body, and  fall  as accurately as possible upon the
middle of the articulation.   At its lower  part, however, it is well to
incline it a little to one side between the apex of the labium majus and
labium minus, or even to separate from the pubic branch one of the
roots of the  clitoris, in order to  avoid afterwards dangerous lacera-
tions.  There  can be no other than  small  arteries to tie, unless the
internal pudic has been divided  by prolonging with too little caution
the division of the parts below.
   To  divide the cartilage, the most certain mode is to incise it from
above downwards and from the cutaneous to the  pelvic side of the
symphysis.   It will always be found sufficient to restrain the bistoury
to some  lines from its point by means of the two first fingers of the
left hand, while the cutting edge is  made to operate with the  right
hand.  This  inconvenience  also is prevented  by introducing the
catheter at the beginning or at least  before commencing the second
stage  of the operation.  By this means we empty the bladder, and
the catheter afterwards serves to push the urethra to the right, while
we slightly incline to  the left the incision  of the infra-pubic ligament.
The  ligamentous  matter having been divided,  greater  precautions
are required, and we  no  longer  cut except  by drawing upon,  so to
speak, the point of the instrument,  and we  cease  to make use of it
as soon as we encounter nothing more to divide of an elastic or re-
sisting nature.
  B.  Various Processes.—We might also, as M. Imbert appears to
have done in several instances on living women, as was done, it is said,
in 1780, at Utrera, in Andalusia, as is suggested also by Aitken (Journ.
de 3Ied., t.  LV.,) and advised by M. Pitrequin, (Bull, de Therap.,
t. XL, p. 275.) divide  the  cartilage  from below upwards, and  from
behind forwards as it  were by puncture, so as to leave  the integu-
ments intact in front.   If it  should happen that the symphysis was
ossified, there would be so little chance of obtaining any considerable
degree of enlargement, that in place  of sawing through the articula-
tion, as Siebold has  done,  I would  prefer  having recourse to the
Cesarean section.  In applying the saw  on the body of  the bone it-
self, outside of the symphysis, as  is recommended by Desgranges, the
operation would be neither more  nor less dangerous, for  it is in the
sacro-iliac articulations that the difficulty is found and not in front.
  C.  The separation  of the cartilage is  scarcely effected when the
posterior branch  of the angular  lever formed by the os ischii, acted
upon by the elasticity of  the  posterior ligaments, produces a certain
separation between the bones of  the pubis, which must vary also ac-
cording to the degree of narrowness of  the pelvis, and  that of the
consistence or softening of the symphyses.  Moreover, I can scarcely
   vol. in.                   69 
546
NEW ELEMENTS OF OPERATIVE  SURGERY.
believe that this, of itself, can  go so far as to become dangerous, or
that it can  be necessary to limit it, as has  been recommended, by
compressing the hips before terminating the operation.   On the con-
trary, we are almost always obliged  to make  pressure with gentleness
and moderation  from before  backwards, and  from within outwards,
upon the spines of the ilium, or to separate  cautiously the thighs of
the woman, in order to enlarge the opening to the proper extent.
   D.  The parturition having been accomplished, the surgeon washes
the woman, approximates the bones of the  pubis together, and covers
the wound with  linen besmeared with cerate, and with lint and com-
presses, and supports the whole by means  of a body-bandage drawn
sufficiently tight to make partial resistance at least, to the re-separa-
tion of the bones.   The patient should continue on her back, and in
the most perfect state of rest.   Her  thighs especially, are to be kept
in a state of absolute repose for the space of six weeks or two months,
which  is the time required for the  consolidation of the symphyses.
In other respects we proceed in the same way in the treatment as for
grave operations, taking care to combat the  symptoms with energy
if any  should supervene.  As the termination of the cure approaches,
no movements or walking are to be permitted except with the great-
est degree of caution.   If there should be ever  so little mobility or
pain remaining in the pelvis the patient should again be placed in re-
pose for a certain length of time.  It is not often found practicable for
the patient to stand up or walk without danger until at the expiration
of three  or  four  months.  Nothing, doubtless, would  be more de-
sirable than the consolidation of the divided symphysis ; but women
in whom this has not taken place have, nevertheless, been enabled to
walk and to stand up, and even jump without being sensibly incom-
moded by it; a  peculiarity which is explained by the great degree
of solidity which has been acquired by the posterior symphyses.  A.
Leroy  and M. Lescure go so far as to say that we ought to encou-
rage this by withholding any bandage  from about the  pelvis;  they
■allege,  and perhaps without being entirely erroneous, that the inter-
pubic void is then filled up by a cellulo-fibrous tissue, which  impairs,
in no respect the resistance of the articulations, and by which means,
therefore, the woman would be afterwards  delivered with much more
ease.
   E. Process of 31.  Galbiati.—M. Galbiati, of Naples, substitutes
for symphysiotomy another operation, which, properly  speaking, is
nothing else than a modification of what had  already been proposed
by Desgranges.   In place of dividing the  cartilage, he recommends
that we should make the section of the body and branch of the pubes
on both sides, between the infra-pubic foramina, as had already been
recommended by Aitken.  By this process the sacro-iliac symphyses
remain intact; we run no risk  of wounding the bladder or urethra;
no traction  scarcely is  made  on the cellular tissue  of the pelvis ;
the consolidation is  readily effected ; no abscess, caries,  fistula, clau-
dication or peritonitis are to be apprehended, and we obtain a  con-
siderable degree of amplification in the sacro-pubic diameter.  Some
trials made upon the dead body, and certain experiments which have
been undertaken by M. Ashmead, induce me  to believe that we ou^ht
not to precipitately reject the suggestion of the Neapolitan professor 
DYSTOCHIA.
547
though  the  essays which he  has hitherto  made  can scarcely be
considered encouraging.  The. operative  process, in  his  method,
moreover, would be rendered very simple, if, as M. Stoltz (commu-
nicated  by the author, October 1st, 1837,) recommends, we should
make use of Ajtken's saw, conducted through a  small incision of the
soft parts, in order to saw the bones from behind forwards.

                   § II.—Cesarean Operation.

   The name of Cesarean section is applied to the incision which is
made into the womb to extract the child from it.  The expression by
a latitude of meaning is also applied since the time of Simon, to those
incisions which are sometimes found necessary upon the neck of the
uterus,  with the view of favoring the passage of the head of the foe-
tus.   The Cesarean section  has frequently been performed with  suc-
cess, though it cannot nevertheless be denied that it is attended with
danger.  Boerhaave and Boer were doubtless wrong in maintaining
that scarcely one cure is obtained  out of 14 operations; it is  at least
certain that it has been performed  a number of times  at Paris during
the last 40 years, and that, including in this number the operation of
M. Dubois in April, 1839, all the women have perished;  that out of
73 cases cited by Baudelocque, 42 were fatal; that out of 106 re-
lated by Sprengel, 45 were fatal; and  that in  231 operations men-
tioned by Kelly and Hull, 123 of the patients died.   We should add
that all the successful cases  certainly have  been published, and  that
the authenticity of a number of those  is a matter of great doubt;
while, according to all appearance, it has not been the same with the
unfortunate cases, the greater portion of which may  well have been
suppressed.   We may therefore affirm that up to the present time the
Cesarean operation has been fatal in at least one case  out of two, and
that Tenon must have been deceived in  asserting that since the  time
of Bauhin, it has been performed  at the Hotel  Dieu on 70 women,
who have survived.  According to J. Burns and M. S. Cooper, there
has not yet occurred a single well-attested example of success in all
Great  Britain, though it  has  been performed  there from  15 to 20
times.   One  could not  imagine  however, a priori, that it would be
so dangerous.  It is true that the wound which we are obliged to
make in the walls  of the abdomen is very large, but the parts  that
we divide are not of a very delicate character.   There are no large
sized  arteries or nerves, and nothing of any importance to be avoid-
ed.  The peritoneum is wounded, but the digestive  organs may be
respected without difficulty.   How often also have we not seen the
most extensive and  most complicated eventrations, and penetrating
wounds of every description in this part, without giving rise to any
other than the most trifling accidents and allowing of the restoration
of the patient ?   Would then the wound of the uterus itself be so for-
midable a circumstance?   Everything  on the contrary shows  that
there is in this organ but a very slight  degree of  irritability, but
little tendency to contract inflammation, and the  most favorable  con-
ditions for the  certain and  prompt completion  of cicatrization.  It
would appear therefore that hysterotomy is not so much a serious
operation in itself, as in consequence of the peculiar state in which 
548
NEW ELEMENTS OF OPERATIVE  SURGERY.
the woman operated upon is situated.  I can scarcely therefore reject
from my mind the idea, that if we operated as soon as the indication
was positively established, without waiting until the patient was ex-
hausted in fruitless efforts ;  that if the uterus had fallen into a state of
torpor, or was at the point of becoming inflamed, if it»was not already
so ; that if peritonitis or metritis were imminent or already developed ;
or if in fine the life of  the patient appeared to be placed  in serious
jeopardy, the Cesarean operation would be far from being as frequent-
ly mortal as it unfortunately has been up to the present time.

              § III.—Examination of the Methods.

   When the Cesarean  operation was not had recourse to  until after
death, it was performed  on the left side  of the abdomen: the  wo-
man,  says Guy de Chauliac,  was  opened by means  of a razor
along the left side, because of the liver, and so much the more so from
this part being more free than the right side ; but since it has been
performed  on living woman, it has been subjected  to more rational
rules.  Among the different processes recommended by accoucheurs,
there are five which have more especially attracted attention; in  one
the incision is made on  the median line, parallel to the axis of the
body;  in the second, outside of the rectus abdominis muscle; in the
third, the abdominal walls are divided  transversely on one side; in
the fourth, the wound is made  immediately above  and in  the direc-
tion of Poupart's ligament; finally, the operation in  the fifth variety
is performed on a line with the crest of the  ilium.
  A. On the linea  alba.—This process, preferred  by Baudelocque,
and now generally adopted in France, England, and Germany, en-
ables us to  avoid the muscles, to divide only upon the linea alba, and
to inflict but very little pain; no artery can be wounded, and we in-
cise the uterus moreover in a direction parallel to its principal fibres.
   B. The ancient  accoucheurs, in operating upon  the side, selected
m general the left one,  and  made an incision sometimes straight, at
other times slightly oblique, and occasionally in the form of a cres-
cent, but always immediately outside of the rectus  muscle.   Accord-
ing to those physicians who have adopted this method, it has over the
preceding the advantage of preventing the bladder from being in any
manner wounded, of allowing of a ready cicatrization, and of pre-
senting less obstruction to the discharge of matters  which must es-
cape from the wound.  As the uterus has almost always undergone
a twisting movement upon its axis  by becoming inclined to the rio-ht
or to the left, it has been supposed  that by incising upon the medTan
line we should come down nearer to its left border  than to the mid-
dle of its anterior region.   It was  also from  this  consideration that
the recommendation has been given to operate upon the side toward
which the uterus has naturally become deviated.   In admitting these
advantages to be  well founded, they would nevertheless, as°it ap-
pears to me, be more than counterbalanced by the danger of wound-
ing the epigastric artery or its branches, of having a solution of con-
tinuity, the lips of which, in consequence of the retraction of the ob-
lique and transverse muscles, it would be almost impossible to keep 
DYSTOCHIA.
549
in a state of approximation, and by the impossibility of obviating the
defect of parallelism in the wounds of the uterus and abdomen.
   C. Lauverjat, «who at  first considered that  there would be great
advantages for hysterotomy upon the linea alba,  endeavored, in
order to avoid the inconveniences connected with  the two methods
above,  to  systematize a  process  which had  already been  in  use
among some practitioners, and recommended that we should make a
transverse incision, five  inches  long, upon the  side,  between  the
rectus muscle and the spinal column.  By proceeding in this manner,
he says, we separate rather than divide the fibres of the transverse
muscles; we avoid  the  epigastric  and  lumbar arteries ;  and come
down upon the fundus of the uterus, the cavity of which forms a fun-
nel which readily admits of the escape of the lochia through  the va-
gina and wound.   The parallelism is very easily preserved, the suture
becomes unnecessary, and the simple position is all that is required
for keeping the lips of the division approximated.  Finally, from the
external angle of the wound occupying a depending position, effusions
into the abdomen are infinitely less to  be  apprehended than in  the
other  methods;  but it may be  objected  to this  method, that  the
fleshy fibres  of  the external  and  internal  oblique  muscles have
necessarily to be divided, that the slightest effort must protrude the
viscera externally, that the uterus from being divided transversely
upon its fundus, the part where its vessels  are of the largest dimen-
sions, must soon  become separated to a considerable distance from
the external opening, and that its  fibres in contracting must rather
interfere with than  favor the approximation of the borders of the
internal division: so that  notwithstanding the two successful results
obtained by Lauverjat, and the preference which appears to be given
to this method  by Sabatier and Gardien, it  is scarcely attended with
less  danger than the  two others.
   D. At the iliac fossa.—I. M. Ritgen especially dreading any wound
to the peritoneum and body of the uterus, has recommended that we
should incise transversely the attachment of the large muscles of the
abdomen above the  crest of the ilium, detach  the  peritoneum down
to the upper strait, and divide the neck of the uterus to a sufficient
extent to allow of the extraction of the foetus.  In the first  place I
cannot  see how it could  be possible to open into the apex of the
womb without dividing the serous  membrane which covers it; then
again the difficulties  inherent in this  process, together with  the dis-
section which has to be made in the iliac fossa, do not appear to me
calculated to render the operation less  dangerous than those which
have been  mentioned.   As far moreover as  I am informed, this
method  exists as yet  only in idea, and nobody, up to the present time,
has ever performed it upon living woman.
  II. M. A. Baudelocque, considering that  the principal dangers  of
the Cesarean operation are to be imputed to the double lesion which
is  made  in the peritoneum, and regarding wounds of the uterus  as
almost necessarily fatal,  has proposed a method which, under this
combined aspect of the subject, appears  to  him to be infinitely pre-
ferable to all the others, and which in reality differs but little from the
preceding.  His incision, which begins near the spine of the pubis, is
prolonged  in a direction  parallel  to  Poupart's ligament  as  far  as 
550
NEW ELEMENTS  OF OPERATIVE SURGERY.
  beyond  the  antero-superior  spinous  process  of the  ilium.   He
  selects the left side because of the inclination of the neck when the
  uterus  has deviated to the right, and the right side in the contrary
  case.   After having divided the abdominal wall without touching the
  epigastric artery, he pushes back the peritoneum from the iliac fossa
  as far down as into the pelvic cavity, and detaches from it, the upper
  portion of the vagina, which he opens  into.   Through this opening,
  which ought to have a certain extent, the finger is to be introduced into
  the uterine orifice, which we endeavor to draw towards the wound in
  the belly, at the same time that we make pressure on the fundus of
  the uterus in an opposite  direction to favor its inversion.  When we
  have succeeded in placing the  neck in  relation with  the opening
  through the abdominal walls, we  leave the labor to the contractions
  of the uterus, or should it  become  absolutely necessary the uterine
  orifice  is to  be dilated  with the fingers, when  the foetus  can be
  extracted either with the hand or with the forceps.
    III.  Aldme.  Boivin and Chas.  Bell, having  a  special dread of he-
  morrhage after the  Cesarean operation, also felt  the necessity of in-
  cising the uterus as  near as possible  to  its  apex, which is the part
  where there are scarcely any vessels to be found.  It would be dif-
  ficult for me,  however, to believe that  an  operation  of this kind
  could be practicable in the  majority of cases,  or  that the laceration
  of the vagina, with the destruction necessarily made in the iliac fossa
  or cavity, would be less dangerous than the simple methodical incision
  of the  peritoneum or uterus, in the manner it may be performed in
  the usual operation of hysterotomy.  I may add also that M. Baude-
  locque, after having made  trial of his operation  of elytrotomy in a
  woman whom he met with  a  Jong time since,  and in which  case  he
  was assisted by M. Hervez  de Chegoin, nevertheless deemed  it  ad-
  visable to recur to  the Cesarean operation, properly so  called.   A
/' single fact, I am aware, does not authorize us  to form rigorous con-
  clusions ;  but this one, and which is the only one in relation to living
  woman, appears to me to impart a great degree  of force  to the  ob-
 jections which had been a priori entertained against the ideas of the
  author.
  rIVr' Another mode of operating, which is somewhat similar to that
  ?[ .riK' and whlch  als° does not appear to differ  much from
  that of M. Baudelocque,  appears  to have been  proposed almost at
 the same time by Physick.  From having remarked that in pregnant
 women  the peritoneum  is easily  separated  from the bladder° and
 neighborhood of the neck of the uterus, this surgeon supposed that by
 making a horizontal incision immediately above the pubis,  we mi-ht
 reach the apex of the womb, and open into  it, without  wounding
 the serous abdominal membrane ;  but  whatever  M W  E  Horror
 may say on this subject this operation is but  little worthy of its  in-
 ventor, and is not of sufficient importance to be dwelt upon.

                    § IV.—Operative Process.

   We should never neglect  to empty the rectum and bladder before

 S^r^TSMT sea 74—d: set- 
DYSTOCHIA.
551
a convex and probe-pointed bistoury, forceps, scissors, suture needles,
ligatures, tubes  of quills, adhesive plasters, and lint in the form of
small balls, and gateaux.  There will also be  required portions of
linen spread with cerate, long and  square compresses, a body ban-
dage, large fine  sponges, a syringe, canulas of gum-elastic, in case of
the necessity of injections, tepid and cold water, vinegar, wine, and
eau de cologne.   The  patient is to be placed  as  far as  practicable
upon the bed, where she is to  be  continued during the first days
after the operation.  Her position ought not to be disturbed.  Being
placed on her back with her head moderately elevated, and her legs
and  thighs slightly flexed, the assistants are charged to pay attention
to any sudden movements that she may be induced to make from the
pains.   Two intelligent assistants are to apply their hands upon the
sides and fundus of the uterus, so as to circumscribe it completely, in
order that no organ  may slip between its surface and the abdominal
walls, and that it may, so to  speak, constitute  one united mass with
these last mentioned parts.  To effect this purpose, the naked hands
appear to me to be not quite so commodious, as when  they are ap-
plied over large portions of sponge, as recommended by MM. Hede-
nus  and Kluge.   The surgeon, with a convex bistoury, incises the
integuments from the neighborhood of the umbilicus to the pubis, to
the extent of from five to six inches.  The sub-cutaneous tissue, apo-
neurosis, and muscular fibres, as  well as  the  cellular  tissue, are,
should we not operate upon the median line, divided in  succession in
the same manner and to the same extent.  The incision ought not to
descend  too near to  the symphysis, because of the proximity of the
bladder,  and that the walls of the abdomen  in this  part usually pos-
sess  a great degree of thickness.   It would  be  better to prolong it
above the umbilicus, while taking care to pass  to  the left of this ci-
catrix, in order to avoid the umbilical  vein,  and especially the anas-
tomoses  which may exist between it and the epigastric vein.   After
having opened through the peritoneum in such manner as to allow of
the introduction of the left forefinger, which is to serve as a director
to the instrument, we enlarge the wound with the probe-pointed
bistoury, so as to give  it the same extent as  the division of the skin.
If, as I saw in the case operated upon by M. Dubois in  1839, the in-
testines should, notwithstanding all our efforts, escape externally, it is
to be well understood that they are to be reduced before we go any
farther.  The uterus is now exposed to view.  We incise it layer by
layer, and with caution, until we come down to the surface  of the
foetal membranes; in order to preserve as much length as possible to
its neck, we direct the assistants gently to depress its fundus by ma-
king a vibratory movement upon it forwards.  We might, in fact,
after the  manner of M. Kluge, seize hold of the lower and deep an-
gle of the wound in order to effect, or at least to  favor a movement
of this kind, which by enabling us to prolong  the section with ease
very high up, would  allow us to respect the apex of the uterus.  Nor
can I see moreover any inconvenience in separating beforehand with
the finger, the placenta and the membranes to a certain extent.  It
is  at this period, and not before commencing  the operation,  that it
might perhaps be allowable to follow the recommendation  of Plan-
chon, and to rupture the membranous bag in the upper part of the 
552          NEW ELEMENTS OF  OPERATIVE SURGERY.
 vagina, either  by means of  the  fingers or  Siebold's  instrument
 Upon the supposition that we perforate the membranes of the foetus
 through the wound, which appears to me to be the preferable course,
 it is important that the assistants  redouble their  attention, in order
 that the abdominal walls may not be separated from the uterus.  We
 should by this means oppose an obstacle to the effusion of the waters
 into  the peritoneal cavity,  while  the  tendency which  the  viscera
 have  to escape  outwards would  be effectually resisted.   The ex-.
 traction of  the infant is to be made without delay  ; when it presents
 itself by the head or breech, we draw it out in this position, and in
 order to aid its escape, direct the assistants to make gentle  pressure
 through the walls of the belly upon the sides of the uterus.   Should
 it present itself in another position, we seize it by the feet, and  ex-
 tract it with the same precautions  as in  parturition through the natu-
 ral passages, while taking care especially not to  displace or make
 traction upon the lips of the division.   Immediately after the extrac-
 tion of the foetus, the placenta is soon forced by the contraction of the
 Uterus to protrude itself into the wound.  We grasp it by one of its
 borders, when that can be done, rather than make traction only upon
 the cord. As to the  membranes,  we take care to roll them up in
 cords as in natural labor, in order to prevent any of them being  left
 in the uterus.  If blood has been effused or formed into clots,  it is to
 be removed with the hand.   It would be well, moreover, to cleanse
 all the parts with an injection of tepid water; but I do not think that
 there would be any utility, with a view of keeping the neck open, to
 place a thin meche in it  as  recommended by Baudelocque, nor any
 species of canula whatever.  These means would  not prevent  the
 orifice from closing, and  without conferring any  advantage  would
 augment its irritation.  The finger, which is to be occasionally intro-
 duced, will be sufficient to open  it again, should  it cease to give egress
 to the  matters, which nothing in  fact  can prevent, from  passing
 wholly or in part through the wound.

                              § III.

  The operation being terminated, we have to look to the suspension
 of the flow  of blood.   In the lateral  process,  and  especially in that
 of Lauverjat, several small arterial branches may have been divided
 which  are to be  constricted  by  the ligature or  by  torsion, unless we
 should prefer to  do this  in  proportion as  they have been opened.
 During the  operation  the principal orifices of the uterine  arteries
 should have been closed  by the fingers of the assistants, nor has it
 ever been deemed proper to apply a ligature to them.   After the
 lapse of a few minutes the incision in the uterus is reduced to the
 extent  of one or two inches, and from that time every kind of hemor-
 rhage becomes impossible.  The wound of the abdomen is usually
 reunited by  means of the interrupted or  twisted suture, which is the
 only means  of preventing a  protrusion  of the viscera.  The lower
 angle of the division should  be  left  free to enable the discharges  to
escape and to allow the meche, one extremity of  which is to be in
the uterus, to conduct  them to  the  outside.  The  points of suture,
moreover, do not prevent our applying adhesive plasters between 
VAGINAL UTEROTOMY.
553
  them, nor from assisting their action by means of a uniting bandage
  and a favorable position.  The wound is afterwards to be covered
  with a perforated linen.  Two long and large compresses are placed
  upon  the sides.  Plumasseaux  and ordinary compresses, with the
  body bandage, all properly applied, will complete the dressing.  An
  antispasmodic potion, rendered slightly opiate to calm the  nervous
  agitation, proper precautions to  enable the lochia to escape through
  the vagina, and not to become  effused into the belly, with  diluent
  drinks, and should the slightest symptom of inflammation supervene
  bleeding and leeches, together with the most perfect repose of body
  and mind, constitute all the advice that the surgeon can give to the
  patient to prevent the dangers with which she is threatened.

                Article XVI.—Vaginal Uterotomy.

    There may be a  great  number of reasons,  according  to authors,
  which would  render it  necessary to have  recourse  to  the vaginal
  Cesarean operation.  An  obliteration with a fibro-cartilaginous indu-
  ration of the neck, as in the case related by Simson, and even  in the
  one mentioned by Van  Swieten;  violent convulsions, which put the
  life of the woman in danger while the orifice is too tense or still too
  little dilated to allow of the introduction of the hand, as is seen in
  the cases of Duboscque and  Lambron; as also an extreme obliquity
  of the orifice backwards, at the same time that the head of the foetus
  drags into the cavity and to the vulva the anterior wall of the uterus,
  which it distends, attenuates and  ultimately lacerates, if we do not
  hasten to make the incision, as Lauverjat did,—constitute the accidents
  which have in most  cases  required this operation.  It may  also be-
  come advantageous  when the uterus, after having escaped from the
  pelvis during pregnancy, has not  been reduced, and when  its neck
,  cannot be dilated by means of the fingers, even though there be dan-
  ger in retarding  the labor, examples of which are related by The-
  nance, Jacomet and  a surgeon of Vaux, cited  by Bodin.  But it has
  been more  especially proposed in cases of scirrhosities, and when
  the orifice presents so great a degree of resistance that the woman is
  exhausted in fruitless efforts to effect its dilatation.   Finally, it would
  be also applicable, as Bodin has endeavored to demonstrate, in cases
  of presentation of the arm, should it ever be  in such cases actually
  impossible to make an attempt to seize the feet, and should there not
  be other means of avoiding the amputation of the limb.  The specu-
  lum, which is employed  by some persons, is not necessary for  this
  operation.   By means of the probe-pointed bistoury protected by a
  bandage and guided  by the finger, We readily reach into the neck, if
  it  is not  too  distant  from the pelvic axis.  In the contrary case, we
  should have to replace  the straight bistoury by the  curved bistoury
  of Pott.   In a case of necessity, we might confine ourselves to a sin-
  gle incision; but as  it is important that this should  not be too deep,
  we should give the preference to several incisions made at a certain
  distance from each other.  At  first  sight it would  appear that the
  passage of the head could not  be effected without enlarging  such
  wounds so much  as  to  prolong them to the body of  the uterus and
  to lacerate the peritoneum.  Nothing of this kind, however, happens,
    vol. in.                      70 
554
NEW ELEMENTS OF OPERATIVE  SURGERY.
 and they are usually restricted to the tissues of the neck.  When we
 operate for a scirrhous or fibrous induration, it rarely happens that it
 gives rise to a  discharge of more  than a few ounces of blood.  In
 such cases  Duges recommends and with reason, as I conceive, that
 we should at the same time remove all the diseased parts, in place of
 merely  incising them.   When we divide the  anterior wall  of the
 uterus without  going as  far as  the orifice, we are obliged in begin-
 ning the operation, which is  always more delicate than in the prece-
 ding case,  to make  use  of a straight  or convex bistoury which is
 not probe-pointed.  In making  the incision we cannot  observe too
 much caution to prevent our wounding the part of the foetus which
 should first present itself.  When, however, we  have penetrated into
 the uterus, the finger becomes a sure  guide, and the wound may be
 enlarged by the instrument, without any danger,  to as great an extent
 as may  be necessary.  We will remark, however, that there would
i not be as much danger in prolonging it posteriorly as in front,  be-
 cause of the proximity of the  bladder, and that it would be, more-
 over, useless to  give it any great degree of extent.  After the deliv-
 ery this wound contracts very rapidly, and frequently the neck has
 already resumed its natural  position  before the  lapse of half  a day.
 Should the  blood  flow in too great quantity, injections with the oxy-
 crat,  together with  tamponing, would  in general arrest it without
 any difficulty, and cauterization, which  could also be applied with
 facility,  could but rarely become indispensable in such cases.  As to
 the lochia, they  will make their  escape either  by the neck or by the
 wound,  and  the woman, in this  respect, does  not require any other
 attentions than those which are had recourse to after ordinary partu-
 rition.   As  to  what relates to cephalotomy, the employment of
 crotchets, cords,  forceps, turning of the child, &c, I  do not think
 it necessary to repeat them here, as I have entered in detail upon these
 subjects in  the  second volume of my Treatise on Tocology, and so  .
 much the less as such operations belong exclusively to the province
 of the accoucheur.  If I  have allowed myself to say a word  on the
 subject of symphysiotomy and the Cesarean section, it is because the
 surgeon is sometimes  sent for to perform these  operations, even by
 those  persons who  exclusively occupy themselves with obstetrical
 practice.  I  refer also to  what I have said, farther back, on the  sub-
 ject of the occlusion of the neck of the uterus  and of the vulva.
   [Cesarean Operation.—The Cesarean operation on the linea alba,
 by Dr. Wolff, in the  case of a woman  aged 24, (Neue  Zeitschrifft
 fur Geburtskunde, Von Busch, d'Outrepont, Ritzen and Siebold, 1840,
 t. XIX.,—also,  Arch. Gen.  de Paris, 3d ser., t. X., 1841, pp.  499,
 500,) in whom  the head of the child,  although perforated by the for-
 ceps, could not, in consequence of the narrowness of  the pelvis, be
 extracted, was perhaps not  altogether justifiable, though the mother
 did recover.  Because in the methodical course  of proceeding, at-
 tempts  should, as the editors of the  Archives say, have been  first
 made to turn the child, as the upper  strait had  full  two inches and
 a half in diameter, and had not that succeeded, the foetus itself could
 have  been detached  in  piecemeal, which was  certainly preferable -
 to a step so  hazardous as that of gastro-hysterotomy.
   Rupture  of  the  Uterus  during Parturition.—M. Velpeau,  re- 
vaginal uterotomy.                   555
marking on a case of this kind, transmitted to the Paris Academy of
Medicine, (sitting of Sept.  12, 1843,  in  Arch. Gen. de Med., tome
III., 4th ser., p. 223, 224,) by M. Castelli, and in which this latter ex-
tracted the child  by the operation of gastrotomy, considers it impro-
per to recur to this extreme surgical  means, until all attempts to re-
turn the child into the uterus, whether it has escaped either partially
or wholly from it into the abdominal cavity, have failed.   In  M. Cas-
telli's case, an exostosis  in the pelvis is stated as the cause.  M. Vel-
peau considers that certain tumors  in this region might be readily
mistaken for exostoses.
   A remarkable  case, in which the Cesarean operation was unne-
cessarily performed by  a country physician in Germany, is furnished
by Professor  Behm, of  Stettin, (Neue Zeitschrift fur Geburtskunde,
1843, t. IX., No. 2,—Arch. Gin. de Med. de Paris,  4th ser., t.  II.,
pp. 103, 104, 105.)   The Cesarean operation had  been performed
under the erroneous impression that there  was malformation  and  ab-
normal contraction of the uterus, which  on the woman who  had  re-
covered from the operation becoming again pregnant four years  af-
terwards, was found  by Prof.  Behm  on  examination  not to exist.
There was, however, a remarkable diminution in the depth and size
of the vagina, this cavity having an extent only of an inch and a half
when it terminated in  a dense fibrous contraction or stricture, pre-
senting so  small an aperture  that it scarcely admitted  of the inser-
tion of a crow's quill.   This may have led to the mistake of the pre-
vious accoucheur.  M.  Behm, by means of dilatation with pieces of
sponge, succeeded in increasing this opening to a small extent,  but
when labor came on at  the full term, a few weeks afterwards, it was
still found to present such serious impediment to the  progress of  the
membranes and head, that he was  obliged  to enlarge'it by the  bis-
toury, after which the delivery was readily  effected  by the  forceps.
The mother and child were both preserved.  It  is a remarkable  cir-
cumstance, say the  editors of the Archives  Gen., (lb. loc. cit.,) that
the cicatrix of the original uterine wound  should have  not ruptured
during the violent  contractions  of. the womb for a  whole day,  the
more so as it would seem that perfect  cicatrization of the uterus does
not always take place,  (see Bulletins  de la  Soc. Anatomique, Mars,
1841.) after the Cesarean operation.
  The Cesarean  operation was in one case first performed by  the
surgeon, and in the next pregancy by  nature herself!   This  is cer-
tainly one of the most remarkable cases on record and can scarcely
be credited.   The  surgeon who gives its details, Dr.  Prael, of  the
Obstetrical Institute of  Hildesheim, (see Neumeister's Allgem.  Re
pertorium der Gesam. Deutsch Med. Chir. Journalistik, June, 1844
also Arch. Gen. de Alid. de Paris, 4e  ser., t. VI., Sept., 1844, p. 114.
&c.,) states that in the first pregnancy of the woman in question, who
was twenty-eight years  of age and with so contracted a pelvis as te>
render parturition impossible in the  natural mode, he performed  the
Cesarean  operation  Jan.  11,  1842, on  the  linea alba  without  the
slightest difficulty, delivering the child alive and perfectly well,  and
dosing  up the wound in  the  uterus  by six points of  suture. The
child shortly afterwards died of trismus, but the  mother speedily
recovered and was restored  to perfect health.  This  woman,  not- 
556          NEW elements of operative surgery.
withstanding the dangers in view, becoming again pregnant in Jan-
uary, 1843,  and the  child being dead, labor shortly after came on,
(July 18,) when a rupture of the uterus  and abdominal walls sud-
denly took place, causing thus the speedy delivery  of the child  by
the efforts of nature alone. The surgeon being sent for, detached the
placenta and  membranes, and  returned  the epiploon,  and  then
brought the wounds  in  the abdominal wall  and uterus  together  by
adhesive plaster.  Their direction was transverse  to  the  original
incision.   The  most  remarkable point is  that  this woman, after a
series of  dangerous  accidents, fever, suppuration,  &c, perfectly
recovered!  No doubt the previous operation paved  the way for the
rupture.
  The Cesarean operation was, it is stated, successfully performed
July 4, 1844, by Dr.  Bresciani of Borsa  in Italy, (Annali Univ. di
Med., Dec,  1844,) on  a young married woman aged  twenty, in
whom the  pelvis and spine were too much deformed to admit  of
natural labor.   In addition to this, the anterior obliquity of the womb
was  such as to preclude the  possibility of adopting any of the ordi-
nary processes, as those of Mauriceau, Baudelocque  and Lauverjat.
The  surgeon, after ascertaining the position of the epigastric artery
on the external border of the rectus abdominis muscle, and directing
the assistant to make compression upon it, proceeded to make his
incision  through  the integuments, peritoneum  and uterus.   The
woman is said to have recovered entirely.
  Successful removal of the uterus by ligature.—The uterus has, in
a recent instance, been  successfully removed entire  by  ligature  by
Mr.  Parsons at Bridgewater,  (Eng.,) April 21, 1844,  (Provincial
Medical  and Surgical Journal,  July 10, 1844,)  in  a maiden lady
aged  sixty years, who had been  troubled  with  prolapsus for sixteen
years; the first three years of which it appears she had persisted in
retaining in  the vagina a large  globular India-rubber pessary, which
she had neglected to  remove occasionally  as had  been directed, and
which produced a discharge so offensive and profuse and had  become
so wedged in  that Dr.  J. Toogood, the former partner of Mr. Par-
sons, and to  whom the case originally belonged, was actually obliged
to deliver her of the foreign body by the forceps !  The prolapsus
then  returned, and suffering from it foi years, the whole body of the
uterus finally extruded itself  from the vulva  in the shape of a pyri-
form, ecchymosed tumor, seven to eight inches  long.   The  taxis
prolapsi, cold  applications,  &c,  proving fruitless,  a ligature was
applied around  the neck or narrow part of the tumor just within the
vagina,  by  which the  whole  organ was speedily  and effectually
removed.   The mass weighed  nearly two pounds, having the  shape
of the uterus but much  altered in character, the cavity being quite
obliterated, and the os uteri  become almost cartilaginous.   No  bad
symptoms ensued, and  the recovery was  perfect.  On  examination
no uterus could be discovered, the vagina appearing to terminate in
a cul de sac  Dr. Toogood says he advised  the  operation  with
greater confidence from  having known of two other cases in which
the whole body of the uterus was removed  by ligature without any
immediate danger; but he is ignorant of their final result.
  The greater portion of, if not the entire  uterus in a case of prolap. 
VAGINAL uterotomy.
£57
feus of this organ, is stated by Dr. Esselman of Nashville, Tennessee,
to have  been extirpated by  him  by ligature, under the impression
that it was a polypus.  Further details are desirable  in this case than
those published in the American Journal of Medical Sciences, (1844.)
The same remark perhaps is applicable to the prolapsed, degenerate
and transformed uterus stated above to have been excised (Provincial
Med. and Surg. Journal, 1844) by Dr. Toogood.
   Spontaneous descent and expulsion  of a cancerous  uterus.—A
case was transmitted by M.  Estevenet, of Toulouse, to M. Velpeau,
(Arch. Gen.  de  Med.,  Sept., 1844, p. 119,) in which a woman, aged
37, affected with a cancer of the womb, was, while at stool, seized
with a prolapse of the  organ, by which the whole uterus was spon-
taneously expelled entire through the vagina !  The  fact was estab-
lished some days subsequently, by  an examination of the parts, after
her death, which was caused by peritonitis.
   Cancer of the  Uterus.—Dangerous mistakes may occur from the
too frequent neglect of examinations per rectum as well as per vagi-
nam, in all diseases in which the pelvic organs are implicated.  Dr.
E. Hocken has given a recent striking illustration of this (Ed. Med.
and Surg. Journ., vol.  CLXVI., Jan. 1, 1846, p. 24,  &c.) in the case
of a woman who was supposed to have a cancerous affection of the
womb or rectum ; but  in whom it was found, upon examination, that
almost the entire colon, and  all the rectum, had become enormously
distended with  hard, impacted faeces, causing apparently acute pain
over the whole  abdomen.   This state of things  had endured for a
month, during which a  partial excretory drain appears to have been
established by the frequent vomitings of the ingesta, and a muco-pu-
rulent discharge  from  the vagina.   Nothing whatever passed per
anum.  The constipation, it would seem, was first caused by the pain
in going  to stool, after she had injured the vagina by a fall, causing
hemorrhage from that  part.   The woman at the  last  report was
nearly quite restored by the mechanical removal of the indurated foe-
ces by means of a lithotomy  scoop.
   Forcible tearing  out of the uterus by mistaking it for a second
foetus.—Prof. Rossi furnishes a perfectly authenticated fact, (Annali
Universali di Medicina, vol. 101, January, 1842,) in  which a woman
aged 28 had the  uterus, in the year 1837, forcibly torn out by a mid-
wife, on the supposition that she was extracting a second child after
the delivery of  the  first.  The most remarkable point is that the
parts left, cicatrized, and  that the woman was yet alive four years
afterwards.   This fact, however, would not, as Prof. Rossi seems to
think, justify a resort to excision of the uterus for cancer.
  M. Riberi has completely excised the urethra, except  a small por-
tion adjoining the neck  of the bladder, in removing  a cancerous  tu-
mor of this passage from a woman  aged 60.  (Translation of a bro-
chure of M. Riberi on this  subject, by Dr. F. Cazalis, Montpellier,
1845, in octavo,  20 pp.)  M.  Riberi knows of no similar operation.
The patient recovered  entirely and  without incontinence.  In the
event of  the operation  being required again, he advises the sound to
be introduced into the bladder as a point d'appui for the instrument
before making the excision.
  Improved Speculum  Vaginae.—One of the best  modifications  of 
558
NEW ELEMENTS OF OPERATIVE SURGERY.
this valuable instrument is that of a skillful manufacturer of surgical
instruments  at New York, Mr. George  Tiemann.   His  improved
speculum vaginae is a modification of the speculum vaginae of Weiss,
in London.  It is composed of three blades, which, when closed, form
a cylinder sufficiently small to be used likewise for any operation in
ano.  Instead of the enlargement  by the revolution of the screw, like
Weiss's, the  three blades open by  compressing the handles  gradually
with the hand, and securing them  by turning the thumb-screw.  The
advantage of this instrument is  this:  the  operator can judge better
how far he  may open  the three  blades without injury, whereas in
turning the screw handle,  he does not feel  to what extent he forces
the instrument.
  This speculum, considered as  one of the most useful, can be man-
ufactured for almost half the price of that of Weiss's, which places
it therefore within every practitioner's reach.
  The instrument on the plate annexed, is a German silver cylinder,
to serve as a reflector when the  speculum is opened and the wooden
plug withdrawn.
SPECULUM VAGINA ET ANI.
CYLINDER AND PLUG 
DIAGNOSIS  OF  VESICAL  CALCULI.
559
PART SEVENTH.

  URINARY APPARATUS.
                        CHAPTER  I.

                  CALCULI OF THE BLADDER.

          Article I.—Diagnosis  of  Vesical Calculi.

  Before proceeding to the treatment of vesical calculi, we should
have first established their existence.

                      §  I.—Natural  Signs.

  Most persons  affected with stone experience a dull  pain, or sort
of weight in the  fundament, and which is increased by the movement
or concussions which the patient undergoes while riding in a carriage
or on horseback, or when he is obliged  to submit to the least jolting.
The urine deposits a whitish sediment, mucosities that are flocculent,
sometimes thready or tenacious, or that are frequently sandy, muddy,
or as it were purulent, fetid and sanguineous.   At the  time of their
emission it sometimes happens that they are suddenly suspended, and
that a simple change of position of the body will again enable them to
flow out with freedom, as if they had been momentarily interrupted
by a valve placed  over the entrance  into the urethra.  The pains
sensibly increase in proportion as the bladder is  being emptied, and
especially immediately  afterwards.   The extremity of the  penis be-
comes the seat of a pruritis, which  incessantly induces the patient to
make traction upon it, from whence it  happens that  an extreme de-
gree of length of the prepuce or penis, in infants particularly, con-
stitutes of itself  a symptom of vesical calculi.  The patients have a
frequent desire to urinate, and some of them discharge from time to
time gravel or fragments of stone of  considerable size.  But these
signs are far from being found combined in the majority of calculous
patients; in  many of them scarcely any are present; on  the other
hand various  affections of the  urinary passages, and which are dis-
connected with  calculi, have in numerous  instances simulated this
ensemble  of symptoms.  A catarrhus vesicae  for example, may be
accompanied with all those changes which have reference to the urine.
If at the same time there should have been an irritation and altera-
tion at the infundibulum of the urethra, the pain, together with a fre-
quent desire to urinate, and the  tractions made upon the penis might
exist in the same manner as  if there was a stone.  The weight  felt
upon the fundament is produced also by a tumefaction of the prostate
gland.   As to gravel and sandy deposits, many persons have them
without  calculi  being  actually present.  The  sign which would ap-
pear to be the most conclusive, that is to say, the sudden suspension
of the passage of the urine, though the bladder  may not be empty, 
560
NEW ELEMENTS OF OPERATIVE  SURGERY.
may be  also met with under other circumstances.  The prostate
may give rise to the production of a fold  behind  the urethra, which
may lead to deception on this point.   The  same  might take place
from fungous tumors or a cerebroid mass formed upon the bas fond of
the bladder.  The same circumstance might still more readily occur,
if the lower wall of the urethra should  give rise to the production of
any polypous or pediculated growth whatever,  and which should
have become prolonged into the neck of the bladder.   A patient who
died at the Hospital of St. Antoine, while I was in that institution, in
1829, presented to me an arrangement of this description.  On many
occasions the passage  of the urine had been  suddenly interrupted
before the bladder was emptied.   This man died, and we found on the
vesical luette that a tumor had been developed, which was similar to
the fibrous tissues of the uterus in  its  density and structure.  This
tumor having a slender pedicle which was very much flattened in the
direction towards the urethra, was of the size of a small pullet's egg.
However little  it was  pushed forward, it closed up  the excretory
canal of  the urine in the manner of a plug.  Since then I  have fre-
quently  encountered analogous  tumors attached  to  the  prostate.
The proof, moreover, that none of these signs are conclusive is  this,
that experienced surgeons have in many cases operated for  lithotomy
upon patients who had no stone.   Such signs, therefore, in themselves
are not sufficient to justify the operation.

              §  II.—Catheterism.—Physical Signs.

  Those  catheters and sounds that are not metallic, are not suitable for
the catheterism of calculous patients.   We make use of such as  are
of silver, copper, gold, or platina.  Nevertheless, these three last
mentioned metals, which have the  advantage of being more  sonorous,
are rarely employed, while the silver sound  is  the one that is generally
preferred. Some persons also have  considered that a solid sound ought
to be substituted for those that are hollow, since, from its being more
heavy and compact, it would enable us to feel  the calculus better ;  but
these are  particularities  of little importance, which the skillful surgeon
may dispense with.   When the catheter is  in the  bladder it is neces-
sary to withdraw its stilette, as  the latter  from some  unexpected
movements might lead  to error.   The thumb, which is kept  applied
upon its shoulder, while the  fore and middle finger embrace it  be-
hind its rings, should entirely cover over the opening.   If we should
allow the finger  which shuts it to  move, a  valvular motion might be
thereby produced, and also a sound which would lead to a deception.
By stopping it up with  a peg, as recommended by Boyer, we should
have no danger from this inconvenience.  We should take care to
introduce it while the  bladder is filled with urine, by  which means
we are enabled  to explore with  greater certaintv all the various re-
gions  of the organ.
  A.  Should the patient be lying upon his back,we begin by movin*
around the point of the sound backwards, and  upon the median line
and to the right and left, inclining it with  more or less force to one
or the other side.  We then, by strongly depressing its shoulder di-
rect it as high as possible towards the summit of the bladder;  after 
DIAGNOSIS  of vesical calculi.
561
which, it is advisable to Bring back its beak again to the neck of the
bladder and its neighborhood, as well as upon the different  points of
the bas fond.  If, after having proceeded in this manner, the sound
does not encounter any calculi, we cause the patient to be seated on
the edge of his  bed, or we may even make him get up and waik a
few steps, as it  likewise may be  advisable, in some cases, to make
him lie down successively in various positions.
   B.  In the last place, the surgeon allows  the escape  of the urine,
and without disturbing  the  instrument,  waits till  the  bladder  con-
tracts upon itself, in such manner as to push the  calculus towards
the urethra and to place it in contact with  the metal.   In the major-
ity of cases these different researches soon  enable us to  ascertain
with certainty the existence of a stone ; but from the mere fact that
we do not find it, we are not therefore authorized  in declaring that
there is in reality no stone.   Small stones sometimes elude  the most
skilful manoeuvres.   Frequently there are pouches (vacuoles) in the
bladder, of considerable depth, so that the sound in passing over these
imparts no sensation of any solid body.  It is not rare, for  example,
to find immediately behind the prostate, a cavity either  to the right or
left or throughout the whole extent of the bas fond of the organ, where
stones of  a certain  size will readily escape  the explorations of the
operator,  as I have myself seen, and as is  proved  also by the  facts
related by M. Camus, (Rev.  Mid., 1831, t. II., p. 283,) and M. Bel-
mas.   It is even proved by the cases since collected by M. Boucha-
court, (Arch. Gen.  de Med., April,  1839,) that in certain patients,
most usually those at an advanced age, this secondary cavity, occu-
pying  the bas fond, and  bounded above  by the prostate, and behind
by the orifice of the ureters and  that portion of the vesical parietes
lying between them, may encase and  retain the calculus, and that it is
usually accompanied with quite an extensive  ulceration of the walls
of the bladder.   This  alteration  constitutes, according to  M. Bou-
chacourt,  a very serious form of calculous disease, for none of the
patients, in fact, in whom it has been possible to identify  it  with cer-
tainty  during life, have survived the operation.   Nor, moreover, is
lithotrity better  adapted to these cases than lithotomy,  this last in
fact being preferable to  the  first.  M. Bouchacourt, in  such cases,
inclines to a preference for the recto-vesical incision.  Under other
circumstances the calculus is, as it were,  pinched up  between two
folds of the bladder, as  it may be also retained  in a special cul  de
sac, whether it be  that the  mucous  membrane  has only  simply
formed a hernial pouch through a laceration in the muscular fibres,,
as so often happens  in what  are called columnar sacs,  (vessies a  co-
lonnes,) or that  an actual cyst has formed around the stone, as F. de
Hilden, (Bonet, Corps de Mid., p. 444,) and Meckel, allege to have
seen, and a specimen of which M. Gensoul has informed me he has
in his possession.  In a  man who died of ischuria in 1833, at the
Hospital of La Pitie, the natural bladder communicated by an ori-
fice of six lines  in extent with a  second pouch, of the capacity of
a demilitre, and  which  contained a calculus.   I  have since  seen
two other cases, which were  in  almost every respect similar.
There were  seven calculi in one of  three  pouches  of a bladdei
which M.  Sanson has shown  to me.
  vol.  in.                      71 
562
NEW ELEMENTS OF OPERATIVE  SURGERY
   C. It may be readily conceived  that if Vie foreign body does not
 present itself entirely naked on some one  point of its surface, cathe-
 terism  would not recognize its  existence,  and that  in other  cases
 it would be by varying the position of the patient, the distension of
 the bladder, and the movements of the sound, that we might hope to
 meet with  it.  When the difficulty arises from  the small  size of
 the  stone, or from  the frictions being too feeble to be  accurately
 perceived, Laennec supposed  that auscultation might be of  some
 assistance.  We then apply either the  ear or stethoscope upon dif-
 ferent points of the hypogastrium, with the usual  precautions, while
 on the  other hand, we are manipulating the instrument in the in-
 terior of the bladder.  By acting in this  manner  no  sound will es-
 cape, and the  slightest concussion of the  instrument  upon the stone
 will be  perceived by the ear.   In order to render this resource still
 more perfect, M. Ashmead, from the fact that air is a  better conduc-
 tor of sound than liquids, has proposed to  fill the bladder with this
 fluid.  By screwing the plate of a stethoscope upon the shoulder of
 an ordinary sound, M. Moreau de  St. Ludgere, (These, No.  247,
 Paris, 1837,) finds, and I have ascertained with  him, that we hear
 the bruits of the calculus  better than by any other method.  But it
 is important that we  should not  allow ourselves to be deceived
 upon the value of processes of this kind.  Whenever  the sound
 freely comes in contact with the  calculus, we feel  it  as well  by the
 hand as  by means  of auscultation.  I advise no one  to assert  from
 the testimony furnished by this last mentioned  process, that  a stone
 exists in  the  bladder, provided we  have not also  obtained  evi-
 dence of this by simple catheterism.  In conclusion, it  is not the feel-
 ing or hearing of the calculus which is the difficult  point, but  that
of touching and striking upon it naked.
   D.  Though in a number of cases the catheter may not encounter
 a stone where one or  more exist, there are other  cases which  may
 lead us to the commission  of an opposite  error.   Exostoses  behind
the pubis, such as have been seen by Houstet,  Garengeot, M. J.
 Cloquet, and M. Belmas, and especially by Brodie,  who met with one
 of the weight of 20 ounces ;  also other  osseous tumors, situated upon
 the ischium, as related  by  M. Damourette, on the  sacrum or coxcal
 bones, as in  the case figured by M. Haber, also an osseous cyst in the
 tissues of the walls of the  bladder, an instance of which is found in
 the work of Boyer, may all lead to deception  on this  subject.  The
 same may arise from the sacro-vertebral projection.  The most  fre-
 quent sources of deception, nevertheless, are to  be  found in the  con-
 texture of the bladder itself.   I have frequently noticed that by ma-
 king the point of the sound glide from  the median line towards  the
sides, a jerking motion is produced, from whence results a sensa-
tion of resistance and of inequalities which are well calculated to de-
 ceive those who are not aware of this peculiarity.  This arises from
 the interior of  the bladder being frequently rugous and bosselated
and from the fibres of its muscular membrane beino- united toother
 into fasciculi that are more or less distinct.   This may arise also from
 the presence of fibrinous or  scirrhous (F.  de Hilden, dans Bonet p
 445,)  masses, or those of any other description developed on its inter
 nal surface, whether they are free or adherent.  However little doubt 
                  DIAGNOSIS OF  VESIDAL CALCULI.               563

may ex'.st on the subject, the operator should not neglect to introduce
one or two fingers of the left hand into the rectum, in order to raise
up the bas fond of the bladder, and to favor the other manipulations
with the catheter.   It is also known that the  fingers placed in this
manner, when  assisted by the application of the other hand upon the
hypogastrium,  have in more than one instance succeeded in identify-
ing the presence of calculi without being aided by the sound.
   E.  These details might seem superfluous, had it not been demon-
strated by numerous observations, that enormous stones may exist in
the bladder, without  the patient  being  conscious of them, and  that
lithotomy has,  notwithstanding the  most skillful explorations, been
performed in other patients in whom no calculi existed.   Every body
knows the history of  the monk who bequeathed his body to the sur-
geons, from the certain conviction in his mind  that he had a calculus
in his  bladder, which nobody  had  been enabled to identify.   The
sound was  introduced, and nothing was found.   The patient died,
when the stone and bladder were ascertained to have passed into the
scrotum, (D. Sala in Bonet, t. IV., p. 432.)  Bartholin (Bonet, Corps
de Aled., t. IV., p. 431,) has  seen something  similar.   Lapeyronie,
d'Alambert, the watchmaker Portalier, mentioned by Deschamps, also
Sabatier and  M.  Richerand,  each of them had an enormous cal-
culus in the bladder,  though none of them had scarcely any symp-
toms  of it.  M. Texier cites another case of this kind, related by M.
Marjolin, in which it became necessary to saw through the bones of
the pubis, in order to extract  the calculus.  On the other hand, we
find in the Journal of Desault, that Le Blanc acknowledges to have
performed lithotomy on a patient who had no stone.   Desault  him-
self,  as well  as Cheselden, (Lassus, Med.  Oper., t.  I.,  p. 403,) ap-
pear to have fallen into the same error.   M. S. Cooper asserts that
he knows seven instances of this  kind, which  occurred to different
surgeons.  M.  Moreau has collected most of the cases  which relate
to this kind of error.   I myself have been enabled to ascertain four:
in the first case the patient was   perfectly restored; the second at-
tempt occurred in the case of an infant, who died ; the third took
place in a public establishment of the capital, and the  patient also
succumbed; and the fourth relates to a young confrere who  is still
living.  Now as all these operations were performed by men whose
learningand skill cannot be called in question, we  may well be per-
mitted to hesitate, when we are compelled to come to a decision un-
der such circumstances.
  F. The prudent surgeon therefore, forewarned of these errors, will
not decide upon performing lithotomy, without having identified the
calculus by means of the sound, not only once, but twice, thrice, or
even a greater number of times still, should the  slightest doubt remain
in his  mind, after the  first exploration.  For greater security he will
also take the precaution to have others confirm what he believes to
have felt himself.
  G. Catheterism may moreover  point out to a certain extent under
what  condition  the calculi, it  has ascertained, exist, their volume,
density, and position, and whether they are movable or fixed.  When
the stone is felt sometimes  at one point  and sometimes at another,
that it escapes on coming into the slightest contact with it, and that 
564          NEW ELEMENTS OF OPERATIVE SURGERY.
 after having touched it we have some difficulty in finding it again, it
 is evident: 1st, that it is completelv  free ; and 2d, that it  is not  of
 very large size.   If, on the contrary, we encounter it on arriving at
 the neck of the bladder,  and that  the instrument touches it in what-
 ever direction we make the research, it is evidently very large, unless
 however it should  have become lodged upon  the tngonus vesicahs,
 or in the entrance into the urethra.
   H. The volume of calculi being an important point to  ascertain,
 attempts have been made at every epoch to discover a mode of as-
 certaining this point.  The catheter may in this respect, when it has
 once reached into the bladder, impart sufficiently accurate informa-
 tion, if we are much practiced in the use of it.   For this purpose it is
 necessary that the surgeon, without allowing the patient to move,
 should attentively watch the first contact  of the two bodies, and af-
 terwards gently pass the beak of the sound from before backwards,
 and over the whole surface of the calculus, or he should endeavor to
 embrace it in the concavity of the instrument, as if for the purpose  of
 bringing it forwards, towards the urethra.  When the bladder is empty
 this manoeuvre will frequently answer to convey a proximate idea  of
 the dimensions of the stone.   Surgery moreover possesses  at the
 present day other means  of arriving at this result.  One of the  best
 would  be in  my opinion the catheter,  (Clinique des  Hopit., t. II.,
 p. 387,) which I have caused to  be  constructed, and which will  be
 described further on.  This catheter  is arranged in such manner that
 after it is introduced, the  two halves  of which it is composed,  by gli-
 ding over each  other in the  manner of a shoemaker's podometer,
 transform its beak into  a forceps  which can  embrace the calculus
 and determine its  dimensions.  The present  lithotritic forceps  will
 still more accurately attain this  object.  We should  be wrong how-
 ever to suppose that we may always, by means of these instruments,
 determine with precision the volume of a stone.  This could not hap-
 pen unless it was perfectly round, or that we have satisfied ourselves
 that  we have grasped it  in a proper manner.  Now the forceps may
have embraced the calculi ,which are to be extracted by one of their
 angles or one of their extremities.   They may also be embraced too
near to the root of the instrument, or only grasped by its extremities.
   I.  We are authorized in believing that the stone is friable, and  of
little consistency, when in striking against it the  sound  gives  only a
 dull bruit, or when, notwithstanding it is of considerable size,  it nev-
 ertheless appears to be very light.  When, on the contrary, the col-
 lision produces a clear sound, and the calculus  cannot  be  displaced
 but with some difficulty, its  density  must necessarily be very con-
 siderable.   When we encounter it always on the same side, and it
 follows the changes in the position of the patient, and when after
 having touched it on one point, the instrument may  pass around  all
 the remainder of the bladder without meeting with  any others, it is
 probably alone.  If, on  the  contrary,  the sound comes in contact
 with one on the right, and then on the left, and if after havino-  placed
 the patient on one of his sides, we can feel it no longer in th<? highest
 part  of the bladder ; if during the catheterism we perceive a collision
which is distinct from  that which the instrument had with the  first
 itone;  and if the  sound  appears  to disturb  in  succession  several 
INDICATIONS.
565
movable bodies,  we may well be permitted to suppose that there is
more than  one calculus  existing at the  same time in the bladder.
Nevertheless, we are easily liable to err in this matter, and the most
exact researches scarcely furnish any thing more  than probabilities,
with the exception of certain cases where the fact is self-evident.
   J. Nor are the adhesions of vesical stones, or their fixity, matters
that are very easy to  determine.  The calculus appears to be im-
movable, sometimes because it fills up  almost the whole bladder, or
because of  the contraction  of this organ, or  from the volume of the
stone itself, and at other times  because  it is  situated  in  a cavity,
though  we may notwithstanding soon after identify it in another  re-
gion.   It may be situated in the urethra at one of its extremities; an
arrangement which many observers have pointed out, and which has
this remarkable feature, that the stone may make only a slight projec-
tion into the bladder, while at the same time presenting a length in
the aggregate of several inches.  The catheter will ascertain this
fact if it meets with a sort of point which can in no wise be  displaced,
near the neck, and a little outside of and towards the base  of the tri-
gonus vesicalus.  Moreover, we cannot perceive how it is possible to
distinguish  by this process those which  are  confined in accidental
pouches, or in small abnormal sacs, from those which have contract-
ed actual adhesions with any part  whatever  of the mucous tunic
It is the same with this part of the diagnosis, moreover, as with  the
  receding:  the catheterism, if well executed, will afford presumptions,
  ut scarcely ever absolute certainty.   Nevertheless, should the  stone
be imprisoned by one of its  extremities in  the prostatic portion of the
urethra, and project at the same time into the interior of the bladder,
an instance  of which is related both by Le Dran and M. Blandin, we
could satisfy ourselves on this point by introducing the finger into the
rectum, while the sound rests against the head of the calculus.   We
shall, however, have occasion to return to these details in describing
the last stage of lithotomy.

                    Article  II.—Indications.

   Lithotomy for a long time was the only remedy applied to indi-
viduals  affected with the stone;  at present we must associate  litho-
trity with it.  Some persons, it is true, get  well without these ope-
rations, while others suffer so little from their  disease that it would be
imprudent to cut them; but the spontaneous disappearance of calculi
is so rare an occurrence that we are not justified in counting upon it.
It is only in those cases in  which the calculus does not exceed the
size of a grape-seed or bean that they sometimes have been seen to
make their escape through the urethra.  If there are others which have
made their way through the rectum or perineum by ulcerating and
perforating the tissues, these moreover are but exceptions which are
almost as dangerous as the operation itself.  It may happen that the
stone from acting only in its quality of a foreign body will, when it is
confined in  the walls of the bladder or in small accessory pouches,
give rise  to but very little suffering  to  the patient, and that  its
existence may, under  such  circumstances, not conflict  with his life
or even the best of health.   Cases related also by Deschamps and 
566 •         NEW ELEMENTS OF OPERATIVE SURGERY.
many  other  practitioners, demonstrate  that  enormous free  calculi
have  not prevented life being prolonged  in  certain  persons  to  a
distant period, or  their continuing in a  perfect  state of  health.
The Count de Rostaing had  two, M.  de la Bossiere one of  four
ounces, M. de Lory one as large as a pullet's egg, and M. Dachant
one weighing five and a half ounces.  An ecclesiastic of Turin, and
another patient mentioned by M. Souberbielle, (Letter to the Academy
Roy ale de Medecine, 26th May, 1835,) had stones of very large size
without having paid any regard to them.

                              § I-

  None of these exceptions however can weaken the rule, so  that as
soon as the existence of a stone is positively ascertained, the idea of
an operation immediately presents itself.  The volume, form,  seat,
and nature of the calculus moreover, scarcely ever oppose such  diffi-
culties to the operation as to compel us to renounce it.  The counter-
indications are nearly the same as  those in all great operations.  It
is well to remark that  as  catarrhus vesicae, the engorgement of the
prostate and the greater part  of the alterations in  the bladder, are
very frequently attributable to the presence of the calculus itself, we
have some prospect of seeing these accidents  disappear after the
extraction of this  body.  A fact  even which many  authors  have
already remarked, and which  cannot be too frequently repeated, is
this, that all other things  being equal, lithotomy succeeds better in
patients who have  suffered much from  the  stone, than  in those  who
had scarcely perceived it or who  have but very recently noticed its
symptoms.
                              §11.  ■

  It  would  be so  much  the  more  important to ascertain  at the
present day the volume, nature, hardness and contexture of the cal-
culus, inasmuch as  the treatment applicable to each case  might in
this manner be very materially influenced.   If, as I saw in an old  man
in 1833, the calculus should be  friable, and  as it were an aggregation
of grains of sand,  or composed, so  to speak, of fragments  of dried
plaster, as in another patient whom I shall mention further on, it is
evident that its dissolution and breaking  up could be more easily
effected and would  be more  simple than by lithotomy.   This friabil-
ity, which existed in a patient  of M. Sanson, (Mem. de la Soc Med.
de Gand., 1835, p. 93,) and in a patient operated upon by M. Lenoir,
(communicated by the author,  April, 1839,) is sufficiently frequent to
require some notice.  Should  the stone on the contrary have a for-
eign body for its nucleus, as I have remarked  in several instances,
and one hundred and sixty-six examples  of which  have been col-
lected  by M. Civiale, (Gaz. Med., 1838,  p.  269,)  lithotomy micrht
become absolutely  indispensable.  Should  the  calculi contain  a  ball
(Larrey, Clin. Chir., t. II.,  pp. 530, 536,)  or  a  portion  of bone  or
fragment  of a barometer or pipe or lead,  (Bull, de la Fac  t  VII
p.  180.) difficulties would present themselves in attempting  their
destruction  by dissolution or by lithotrity.   Those which include  a
pin, (Petrequin, Gaz. Med., 1837, No. 42, feuilleton,) a needle  ear of 
LITHOTOMY.
567
wheat, lint, a portion of sound or bougie, would be nearly in the same
condition.  Nevertheless, if the nucleus of the calculus were a pea or
portion of a stalk of grass, or a clot of blood, as has been seen by
MM. Larrey (Gaz.  Mid., 1838, p. 677) and Chelius, (Clin. Chir.,
t II., p. 230,) it might yet be practicable to break it up.

                              §111.

  As to the treatment of calculi without an operation, it would  ap-
pear, at the present day, to have a tendency to come into new repute.
Without speaking of galvanism and electricity, made trial of by MM.
Gruithuysen, Pravaz, Bonnet, (Arch. Gen. de Alid., t. VIII., p. 254,)
and Bellanger, (Thise, No.  105, Paris, 1837,) or of injections, as re-
commended  by M. Thibault, (Arch.  Gen. de Med., t. XL, p. 302,)
or  of bicarbonate  of soda  by the method  of M. Robiquet, (Bull.
de  Ferr., t. VII.,  p.  275,)  or of the dissolving liquid  which  an
Englishman, under the patronage of M. Donellan, proposed to me in
1838, I have to remark that the observations and facts published up
to  the present time by MM.  Chevallier, O. Henry, A. Berard,  and
C.  Petit,  (Expose d'un rapport a VAcad. Roy. de Med., 1839,) plead
already strongly in  behalf of the  mineral waters of Vichy, used in
the form  of baths  and drinks and injections.   These waters, which
modify the bladder in a beneficial manner, act by dissolving v&rious
kinds of calculi, and by disintegrating others by their influence upon
the urine or  on  the animal substratum  which agglutinates  its
salts.  This, therefore, is one of the remedies  which  are  to be
made trial of when the stone is not very large, and when there is no
opportunity of immediately  removing it from the patient.

               Article III.—Lithotomy,  (Taille.)

  Lithotomy, which has always been associated with the history of
vesical calculi, is one of the  most  ancient operations of surgery and
also one  of the most dangerous.   No one operation, perhaps, has
given occasion to so many labors, discussions  and efforts of every
description.  Its object is the extraction through an artificial passage
of the foreign bodies arrested or developed in the bladder.
  Though the word taille may be but little scientific, and, in itself,
insignificant, I  nevertheless make use of it in preference.   The term
lithotomy has,  in these cases,  an  acceptation wholly objectionable,
and that of cystotomy is scarcely less objectionable, inasmuch as it is
the  urethra  and not the bladder which is most usually cut into.
Everybody, moreover, knows what is meant by the word taille, (cut-
ting,)  and this is sufficient  to justify its use.  Hippocrates, without
describing it, points out this operation  at considerable length, and
shows that there were then, as at the present day, itinerant surgeons
who occupied  themselves with no other than this.  Moreover, it ap-
peared to be so dangerous and  so improper to the father of medicine,
that he made  his pupils take an oath never to perform it, an oath
which, if history is  to be believed, was not without its use, inasmuch
as certain lithotomists of that time who had been suborned by the
usurper Tryphorus, were so depraved as to perform lithotomy on the 
568           WEW ELEMENTS OF OPERATIVE SURGERY.

young Antiochus VI. when he had  no stone, and  so as to cause his
death during the operation.  Celsus, who was  the first who has in
reality described this operation, endeavors to show that lithotomy is
not applicable except to individuals under the age of fifteen years
This is what would appear to have been the doctrine of the  Alexan-
drian school, and also of the majority of authors up to the  time of
Marianus Santus.   From that period it has been performed at every
time of life and  in both sexes.  Formerly lithotomy was  performed
only in spring-time.   It was at this season that calculous  patients
were assembled  in the hospitals,  and also in the  towns, where
they were met by the lithotomists who came to operate upon them.
This no longer takes place at the present day.  Lithotomy, like all
other operations  in surgery, is performed at every season of the year;
except that the stone is a slow disease, and one in which it is not dan-
gerous in a great number of patients to defer the operation for some
months.  But as, on the other  hand, too  cold  or  too  hot a season
would appear to be less favorable  to  its success  than  the others,
autumn and spring continue to have the preference when there is no
necessity of any haste.   A precaution  to  be taken before cutting a
patient is to ascertain  whether the urethra is  perfectly free.  We
sometimes,  moreover, accomplish this without any design to do so. In
fact it is  necessary, in order to ascertain the  presence of the calculus,
that we should penetrate through this passage.   But should it be con-
tracted, the catheterism might be found impossible ; in which case,
therefore, before having recourse to lithotomy, we  should submit the
patient to the treatment applicable to diseases and coarctations of the
urethra.  The other preparative means consist of  a bleeding, a few
days of light diet, and a gentle purgative,  with  the view of relaxing
the intestines and  preventing sanguineous  congestions.  I have no
necessity of remarking that where  any accessory  lesions  exist that
are independent  of  the principal affection,  we ought, before all other
things, to attend to these and effect their cure.  We  should never
fail to administer on the evening  before, or even on the morning of
the operation, such an  injection as would  perfectly cleanse  out the
rectum.  When  the operation is once determined upon there is still
left an important question to be decided: by what  method is it most
advisable to extract the calculus?   The principal methods are three
in number;  one  which  consists in penetrating into the bladder at the
perineum ;  another which gives the preference  to the route  through
the rectum; and  the  third,  which reaches the stone through  the
hypogastrium

         §  I.—Perineal Lithotomy, (the lower operation.)

   Lithotomy at  the perineum, which is the  most ancient of all, has
been performed  in so many different Ways that it becomes indispen-
sable, in order to  analyse their processes with any advantage, to
unite them together in  classes and to assemble those which have the
most analogy to each  other, in order  to form  from them a certain
number  of principal methods.  In some of these processes we reach
the  calculi  without dividing the urethra, while in others the most
distant portion of this  passage is  always traversed by the instru- 
LITHOTOMY.
569
ment.   Among the first are to be classified those which relate to the
lateral operation, a method which would appear to include the pro-
cess of the ancients, that  of Frere  Jacques, that of Foubert, &c.
The median or great operation, whether oblique or  by the lateral
method of Frere Come, &c, belong to the second class.
  A. The  lateral method, (Cystotomy, properly so called.)—I. The
process of Antylus or Paul of Egina, vulgarly known as the little
operation.—The description given of lithotomy by Celsus had been,
as it would appear, up to these latter times, the subject of inter-
pretations  that were altogether erroneous.   The  result of this  has
been that the  process known under the name of Methodus Celsiana,
does not in reality belong to  him.   We  must go to  the Greek au-
thors to find the principle of this operation, while  the actual process
which Celsus  adopted,  belonged to  the school of Alexandria.  As
Antylus is  the  first  who  has given a clear description of it, it is
proper in my  opinion to designate it under the name of this ancient
author.  To perform this operation, the surgeon introduces two fin-
gers into the rectum, and  endeavors to grasp the  stone through the
walls of the bladder, while with the other hand he makes pressure
upon the hypogastrium, with the view of favoring its descent.   Hav-
ing seized the calculus he  pushes it against the urethra, between the
anus and the  scrotum, and a little to the left of the perineum.   He
then incises all the soft parts down to the stone, in the direction of a
line which would extend obliquely from above downwards and from
before backwards towards the left ischium, arrives in this manner into
the bladder and expels the calculus through this opening  by  means
of the fingers which  have been  kept in the rectum.   A species of
scoop, having  points on its interior, is introduced through the wound,
in order to seize the stone and bring it to the outside, when the opera-
tor  has not been enabled  to expel it by his fingers.   This method,
which is known under the name of the little operation, on account of
its great simplicity, and which  subsequently received the name of the
Guydonian method, because it appeared  to  have been overlooked
until Guy de Chauliac revived  the knowledge of it in 1363, was nev-
ertheless described by a number of authors who  lived anterior to
this last mentioned  surgeon.  Guy de Salicet, for example, as clearly
points it out as Antylus does.   Paul of Egina, Albucasis, and most of
the Arabic  surgeons also so understood it.  Ali-Ebn-el-Abbas, among
others, explains it in this manner: " You will take a cutting instrument
and  incise," he says, " between the anus and the  testicles, not upon
the median  part, but  by directing the instrument  towards the  left
part of the thigh.  The incision should be oblique, in order that the
opening may be  large and proportionate to the volume of the calcu-
lus."  Ebn-el-Couf, another author of the same epoch, some fragments
of whom have been translated  by M. Clot, (Gaz. Med., 1830, p. 167,)
gives a description  which is in every respect similar.  I classify this
process under  the lateral operation or cystotomy, properly so called,
because in  following it we  cut into, at least in most  cases, the side of
the  neck of the  bladder and not into the  urethra or prostate.   It is
easy to conceive, in fact, that  the fingers  can but  very rarely bring
the calculus into the prostatic portion of the urethra, and that they must
merely  secure it upon the trigonus  vesicalis, and that it must  be
  vol. in.                      72 
570
NEW ELEMENTS OF OPERATIVE SURGERY.
 through  the  walls  of the bladder itself that  the calculus  is  de-
 pressed  to the perineum, and laid bare by the  cutting instrument.
 The objections that may be made to  this process are, besides  the
 difficulties of seizing and grasping  the stone with the fingers, and of
 incising with precision the tissues down to the calculus, and effecting
 its expulsion through so irregular an opening ; that of wounding the
 bladder itself outside of the prostate and thus exposing to effusions
 into the  sub-peritoneal cellular tissue, and  to urinary fistulas, and
 especially to  the wounding of the vesiculae seminales, without abso-
 lutely being exempt also from lesions to the rectum and vessels of
 the perineum.
  II.  Process of F. Jacques.—I  have remarked  that the process of
 F. Jacques,—I speak now of his primitive  process,—belongs to  the
 lateral method.   This singular man, who was at first a simple domes-
 tic  of Pauloni, a Venetian, and who  soon after  became  a  monk,
 commenced his operations at Besancon in 1695.  When he came to
 Paris two years subsequently, recommended by influential persons
 to the canons of Notre Dame, as the possessor of a new method for
 the  extraction of calculi, he was in the habit of  using the following
 process :  A cylindrical sound and without any groove was introduced
into the bladder; plunging in afterwards a  long knife between the
anus and tuberosity of the ischium, F. Jacques  penetrated into the
bladder and enlarged his  incision  by carrying it obliquely inwards
towards  the symphysis pubis; if after  having withdrawn his  litho-
tome, the incision did  not  yet appear to him to be sufficiently large,
he increased  its dimensions in  the direction towards the bladder  by
means of a second knife of the shape of a scraper ; finally, he grasped
the  stone with a tenaculum and terminated while exclaiming to the
patients, like Pare :  / have operated upon  you, and may God cure
you !
  Every body must  perceive  at first sight, that Frere Jacques, by
penetrating on one  side of  his catheter, avoided  entering by the
urethra, and that he reached directly into that portion of the bladder
which is protected by the prostate, or a little outside of this gland.
He  divided, therefore,  nearly  the  same  tissues  as the Greek and
Arabian surgeons ; with this difference, that his  wound must  have
been more uniform, at the same time that its dimensions  were such
that they could be  altered with  greater  ease, according  as cir-
cumstances  required.  Experiments made by the lithotomist Bau-
lot  or  Beaulieu, as he was also called, upon  the  dead body at  La
Charite, in presence of Marechal, and at the Hotel Dieu under the
eyes of Mery, show that he was  far from cutting down always upon
the  same parts ; that he frequently divided  the rectum or vagina in
women, and the vesiculae seminales in  man, and that he especially
wounded the  side of the bladder at the point where  it enters into
the  prostate,  to form  the urethra.   The  shoemaker  that Duchesne
took to him at Fontainebleau, and whom  he operated on in pre-
sence of Felix, Bourdelot, Bessiere and Fagon, and  who was seen
 walking about the streets at the expiration of three weeks was not
withstanding, according to F. Collot, left with a urinary fistula   Out
of 60 patients confided to his care in the two principal hospitals  of
 Paris, 13 only were completely cured;  23 died, and the others were 
LITHOTOMY.
571
left with fistulas, wounds of the rectum, &c.   As soon as F. Jacques
had adopted  the modification which was pointed  out to him  by
Mery, Fagon,  Duverney, aad Hunault d'Angers, and which con-
sisted in making a  groove on  the  convex  portion of his sound,
his method was in reality no longer the same, and it  is to set out
only from this point that it can be received among the uretro-prosta-
tic methods, and that it has become the source of a great number
of useful improvements.   We shall return to it again in speaking of
the lateral operation.                             *
   III.  Process of Raw.—.Though it were true, as S. Albinus alleges,
that Raw reached the side of the bladder without introducing his
lithotome upon the groove of the sound, his process would  still have
to be ranked under the lateral  operation, or under the method  of
Jacques or that of the Arabs ;  but as history has furnished nothing
authentic on this point, it is unnecessary to dwell upon it.
   IV. Process of Cheselden.—It is evident that the first process,
at least, of Cheselden, would come  under the same category, inas-
much as the distinguished surgeon  of  St. Thomas's confined him-
self at first to laying bare the membranous  and prostatic portions
of the urethra, in order to divide the parts afterwards from behind
forwards, commencing at  the neck  of the bladder, and without fol-
lowing the groove in the sound.
   V. Process of Foubert.—The secret that Raw persisted in keep-
ing  in respect to the details of his  method, which in fact was no
other probably than  that of Frere Jacques, which had been at first
so zealously attacked by him,  induced a  great  number  of sur-
geons to endeavor to  ascertain a mode  of  performing  what was
called at that time the lateral operation, that  is to say,  lithotomy
at the side of the bas fond of  the  bladder.  After having endea-
vored to attain  this  object, by varying the application  of the sound,
and  the  extent and  direction  of  the incisions,  they  succeeded
in constructing  a method  different  apparently  from all the others,
and which Foubert, its inventor, supposed to be that of Raw.  This
surgeon  plunged in  a long trochar  at  some lines distant from  the
tuberosity of the ischium, and obliquely upwards, inwards, and for-
wards, until he reached into the bladder.  The groove of the instru-
ment immediately allowed the  escape of a  few drops of  liquid  ex-
ternally, which, with the absence of resistance perceived by the ope-
rator, served to indicate the entrance of the  trochar into  the blad-
der.   This  groove  also served  as  a director  to the  lithotome of
Foubert, which lithotome  consisted  of a bistoury from four to five
inches long, somewhat convex, and  bent near its handle, and on the
side of its cutting edge,  into an angle of from 20  to 30 degrees.
Having arrived into the bladder, this knife was directed in a course
parallel to the ischio-pubic branch of the pelvis, that is to say, ob-
liquely  from behind forwards, and from without inwards, in  order
to give to the bladder and perineum a wound  corresponding with
the presumed  dimensions of the calculus.
   VI. Thomas, a surgeon of  Salpetriere,  though he adopted  the
same ideas, nevertheless deemed it advisable to  follow another pro-
cess ; he plunged in his trochar at the place where Foubert termina-
ted his incision, which he did with a view of dividing the parts from 
572          NEW ELEMENTS OF OPERATIVE SURGERY.
above downwards, and from within outwards, in place of proceeding in
an opposite direction, as the inventor of the method recommended is to
be done.  Moreover, he finally transformed into a kind of concealed
lithotome, the instrument which he had made use of for the puncture.
Manv persons were operated upon by this method, in the hospitals of
Paris, and it was also submitted to some trials in England and Germany.
Numerous objections, however, were soon raised against it.   1 he di-
rection of the axis of the  pelvis, and  the deep-seated position of the
bladder, do not allow of a trochar being passed through the perineum
without danger.   Nothing would be more easy in such cases, than
to deviate by mistake either  in front, posteriorly, or to one side, and
thus to wound the rectum, vesiculae seminales, ureters, or peritoneum
itself, or to penetrate into the  bladder, at  too high  a  point upon its
body.  To all these unquestionable objections, there is one more to be
added, which of itself would  be sufficient at the present day to cause
the rejection of Foubert's method, were it ever possible for it to be
revived.   It is that the object itself, which is to be obtained, is an ob-
jectionable one.  As the incision of the bladder has to be made out-
side of and above the prostate, between the peritoneum  and pelvic
fascia, the least quantity of urine effused into the bottom of the wound
might give rise to inflammation of the cellular layer which lines  the
pelvic cavity, and in this  manner speedily terminate in death.   The
previous division of the perineal layers, as has  been recommended
by Pallucci, in order to allow the forefinger to feel the fluctuation in
the bladder before plunging in the trochar, would only remedy the
least of its inconveniences.  The ingenious sound contrived by Lecat,
and  which, after being introduced,  shut  up,  may,  when opened,
stretch the bas fond  of the organ, and render the introduction of the
principal instrument  more easy, would not succeed any better.   The
instrument contrived by M.  Schwartschild,  (Bull, de  VAcad. Roy.
de Med., t. III., p. 11,—Arch.  Gen. de Med., 3d  ser.,  t. II.,  p. 372,)
would be  still less efficacious.

          § II.—Median Lithotomy, (the great operation)

   The processes which comprise in their incision a part of the urethra,
and which are the only ones  which can be adopted in infra-pubic litho-
tomy,  are also  those which  have most  engaged the attention of
lithotomists.   It is under these that we shall find the median taille, or
great operation, the  lateralized taille, or  that of  Frere Jacques im-
proved, also the transversal  taille, together with  all their modifica-
tions.
   A. Process of Mariano.—The method  which has been designated
under the name  of the great operation, in consequence of the numer-
ous instruments  that it requires, remained for a long time a family
secret.   It was, according  to  all appearance, invented by some of
those inhabitants of ancient Norcia, in Italy, who had  acquired a
great reputation as operators, about the 14th and 15th centuries, under
the common title  of Norcini.  The archives of Turin, moreover,
prove, if we may believe M. Bonino, that Battista da Rapallo,  who
died in 1510, and was preceptor of Giovani, was the  real  inventor
of this process.   However this may be, Giovani di Romani  is  the 
LITHOTOMY.
573
first person to whom history ascribes it, and it was Mariano Santo,
his friend, who published it about the year 1520 or 1530.  A. Bene-
detti,  however, was probably acquainted with  it; for after having
announced that we may extract certain calculi without a bloody ope-
ration, he says, " Nunc inter anum et cutem, recta plaga, cervicem
vesica incidunt."   It only became celebrated by the cures of L. Col-
lot, to whom O. Da Villa had taught it, and who on that account was
appointed lithotomist to the court of Henry II.   At this epoch, the
great operation was always kept secret from the public.  P. Collot and
R. Giraud, who succeeded their relative, were  so unfortunate with
the ten students to whom they were employed to teach this process by
order of the government, that their children  alone would have pre-
served the secret until F.  Collot should have thought proper to pub-
lish its details, had not the  pupils of La Charite and the  Hotel  Dieu,
contrived to make a hole through the ceiling of the operating ward, in
order to see them at work, and in this manner to become acquainted
with  their method.   These then are  the  details of the process: a
grooved sound introduced into the bladder, enables us to depress the
perineum a little to the left of the raphe, and not exactly upon the
median line, as Heister alleges.  The surgeon, with a lithotome simi-
lar to an enormous lancet, incises the skin, cellular tissue, and mus-
cles, from the root of the scrotum to within a few lines  of the anus,
then divides the bulb of the urethra, and arrives in this  manner into
the groove of the sound.   A director, which is a sort of stem formed
of a male and female branch, differing from each other  in this, that
the first terminates in  a blunt and slightly flattened extremity,  while
the other is bifurcated in the same direction, is immediately introduced
into  the bladder  in place  of the lithotome.  The sound, which has
become useless, is immediately withdrawn.  The female branch  of
the director, which has remained outside up to  this time, is now gli-
ded by means of  its  bifurcation upon the square edge  of the male
branch, until it has reached into the bladder.  The two  branches  of
this instrument being thus fixed upon each other, enabled  the surgeon
to dilate the wound by separating them at  their external extremity,
which terminates in a  cross,  in order to render the manipulations
more easy; but their special object  was that of guiding  the tenacula
which were intended to grasp the calculus.  Also an ordinary gorget,
as well as another instrument called a dilator, formed of two branch-
es, articulated in the manner of a scissors, and which were introduced
shut up  and opened,  by pressing upon the rings which terminated
their  outer  extremity, were  sometimes substituted  for the  above
mentioned instruments.   The great  operation, performed literally ac-
cording to the details  laid down by Mariano  Santo, is one  of the
most objectionable methods that have been invented.  The incision
evidently had  to  fall  upon the bulbous  portion, or in  any  event
upon the membranous portion of the urethra.  The dilators could not
enlarge the wound without lacerating the prostate.  The urethra it-
self was  sometimes completely torn, while  its lacerations frequently
extended as far as to the neck  of the bladder, and the vesiculae semi-
nales.   The  contusion of the veru-montanum, and the lacerations of
the ejaculating ducts, involved among their consequences fistulas, or
an incontinence of urine, swelling of the testicles, and  frequently ste- 
574
NEW ELEMENTS OF OPERATIVE  SURGERY.
rility.   The incision into the integuments, if too much prolonged in
front, favored the infiltration of blood, urine, or pus into the scrotum.
The bottom of  the wound, moreover, became in  a great number of
persons the source of purulent collections, which extended either
around  the rectum,  or towards the  pelvis or the upper part of the
thighs.  The operation, in fine, in its ensemble, was exceedingly la-
borious, and so  dangerous that, according to the editor of the works
of F. Collot himself, a cure was rarely effected in the third or half of
the patients who had the courage to submit to it.
   B. This method has  undergone quite a number of modifications.
Already at the time of Dionis and La Charriere, the director and di-
lator were no longer made use of;  for after having extensively in-
cised into the urethra, they confined themselves  to conducting upon
the groove of the sound, a gorget to as far as beyond the neck of
the bladder, which gorget afterwards served as a  director to the or-
dinary tenacula.  Marechal  and Mery had simplified it  still more.
After having made their first incision,  like the Collots, they plunged
the lithotome into the bladder by a combined vibratory movement,
executing  by this motion what the surgeons at that epoch denomi-
nated the master stroke, (coup de maitre,) and in such manner as to
divide almost the entire substance of the prostate in its posterior di-
vision,  (rayon.)   D. Schacchi and C. de Solingen  had already for-
mally advised that  we  should cut those parts which Mariano pre-
ferred  to tear.   It  is evident that  Marechal, by proceeding  in this
manner, incised the  membranous  and prostatic portions of the ure-
thra, and that he was enabled consequently to have an opening of
from 8 to 10 lines at the neck of the bladder, and to extract calculi
of very considerable size without causing the slightest rupture; he
thus obtained a considerable number of cures, and terminated his
operation with surprising  rapidity.  The dilatation by means  of the
finger,  as  De la Faye recommended,  would have  doubtless been
less dangerous  than the instruments of Giovani, but it cannot be
compared to the modification of Marechal. •
   C. Process of Vacca.—Modified in this manner, the great opera-
tion appears to have been divested of so many of its dangers,  that a
surgeon of repute undertook to reproduce it as a method of his own
invention.   After having for  a long time eulogized and employed the
recto-vesical taille, Vacca (Bull, de Ferr.,t. VIII., p. 72) finally sub-
stituted in  its place a  modification of the process of Mery.   The
Tuscan surgeon incises in fact with an ordinary bistoury, upon the
median line, after the manner of Mariano, then  comes down  to the
membranous portion of the  urethra, and afterwards fixes into  the
groove  of the sound the tongue of his lithotome bistoury and pushes
this instrument into  the bladder, from the interior of which or«-an he
then brings it out by elevating his wrist and in  such manner as to
divide the prostate as extensively as he wishes.   M. Jameson, (Bull.
de Fer., t. VII., p. 274,)  who makes use of small forceps-tena'cula to
extract the calculi, also incises the parts nearly upon the median line.
   D. A thesis supported by M. Treyeran. (Parol, des Dif. 3Ieth., &c.,
in 8vo,) at the beginning of the present century, exhibits' another'mod-
ification of the median operation.   The urethra and the prostate are
laid open from before backwards ; a dry slip of carrot is then inserted 
LITHOTOMY.
575
every morning into the bladder through the wound, while the calculus
is not extracted until after the extirpation  of some days.  Guerin of
Bordeaux, (Bull, de Fer., t. X., p.  276,)  who was the inventor of
this process, obtained, it is said, decided success from it.
  E.  The median operation  reduced to its greatest simplicity, pos-
sesses but one indisputable advantage, which is that of not  exposing
to the risk of hemorrhage.   Vacca, who accords to it  moreover the
advantage of  allowing of the extraction of the stone  at the widest
portion of the lower strait, had undoubtedly not reflected  upon this
assertion  ; for in this respect it can effect  nothing more than a great
number of other processes belonging to the lateral operation.  With
the improvements of Mery and Vacca, it is less painful, more ration-
al, and infinitely better in every respect, than when it came from the
hands of  Mariano ; but it is nevertheless the most dangerous of all in
respect to the rectum, nor does it allow us to respect the ejaculating
ducts.  Moreover, as it divides the prostate from before backwards
in the direction of one of the smallest lobes of this gland, it does not
in  reality deserve the eulogies which have been lavished upon  it
by M.  Balardini and by M. Clot, (Compte-rendu, &c, p. 4, 1832,)
which  latter moreover states that he has performed  it in  13 cases
with success.

           § III.—The Oblique or Lateralized Operation.

   It was  from having improperly confounded the method pointed out
in the work of Celsus, with that described by Paul of Egina and An-
tylus,  that the error also was finally committed of confounding the
lateral method, such as it was first performed by Frere Jacques, with
the lateralized operation, which  has since been so extensively intro-
duced into practice.  A great difference however exists between these
two modes of proceeding.  In one the incision is principally designed
to come down upon the side of the neck of the bladder, without neces-
sarily involving the urethra; in the  other, on the  contrary, the  pos-
terior portion  of  this passage is always divided, while the bladder it-
self may,  if necessary, be respected.  The lateralized operation con-
sists essentially of an oblique incision into the prostatic portion of the
urethra, comprising at the same time a  more or less considerable ex-
tent of the membranous portion of the same passage.   The only pro-
cesses therefore  which  belong to  it are evidently  those  in  which
the operator makes use of a grooved sound to direct the cutting in-
strument  into  the bladder.
•  A.  Process of  Franco or of Hunault.—The idea  of the oblique
method has so little  to do  with F. Jacques, that this  monk did not
adopt it, but because of the representations of his antagonist, and not
until after it had  been very clearly described by Franco, as well as
by F. de  Hilden.  Franco (Theses de Halter, t. III., French transl.)
states positively, that in order to incise  the perineum  in lithotomy, a
curved and grooved sound must be previously introduced into the
bladder, that this sound  is to be used  as  a director to the   bistoury,
and the neck of the bladder to be divided obliquely from  within
outwards, and in  the direction  towards the ischium.   It is true that
he recommends, like Tarin, (Ibid., t. II.,) that this incision should be 
576
NEW ELEMENTS OF OPERATIVE SURGERY.
 made to the right, but it is possible that in expressing himself in this
 manner, he meant to the  right of the  surgeon, which would corres-
 pond to the left of the patient.  G. Fabricius evidently adopted the
 same rule, which had already been recommended also  by A. de la
 Croix. It is to Hunault of Angers, however, that we are most indebted
 in this matter.  Certain plates which he had executed, but which have
 never been published,  demonstate that by  means of the grooved
 sound we will  always be sure of incising  the same parts.  It was
 after having adopted his advice that F. Jacques,  in 1701, was enabled
 to operate upon 38 calculous patients,  at Versailles, without losing  a
 single one, and also upon the 22  patients collected by the Marechal
 de Lorges, at his hotel in 1703, and it  was also by this operation that
 he obtained such brilliant success in Holland, and again upon his re-
 turn to France.*  However this may  be, public attention having for
 a time been diverted from its legitimate object  during the first half
 of the last century, was not enabled  to comprehend  at first all the
 importance of the grooved sound,  and  of the  oblique operation, prop-
 erly so called.
  B.  Process of Garengeot and Perchet.—Garengeot, who discov-
 ered  it while making with  Perchet, a surgeon of La Charite, trials
 upon the dead body, and put it into execution in the case of a child eight
 and a half years old, in 1729, while Morand  had gone to London to
 learn it of Cheselden, is the first person who appears to have re-estab-
 lished the oblique operation for lithotomy upon the principles which
 Hunault  had  first laid down.  The sound being introduced into the
 bladder is consigned to an assistant, who presses it  towards the left
 side of the perineum.  The surgeon makes an oblique incision from the
 raphe to the middle of the space which  separates the ischium from the
 anal opening, with an ordinary bistoury or lithotome.  This incision,
 which ought to commence at about an  inch in front of the anus, com-
 prises the integuments and the sub-cutaneous layer.   The  left  fore-
 finger afterwards serves as a  guide to the cutting instrument,  while
 we divide the other tissues,  layer by  layer,  and open  into the ure-
 thra.   The lithotome, glided from  above downwards or from before
 backwards upon the groove of the sound, penetrates into the bladder
 while cutting through the prostate obliquely outwards, backwards,
 and to the  left;  after which the surgeon makes use of this knife to
 enlarge the whole  wound  while  withdrawing  it, and by making
 pressure  upon it with a greater or less degree  of force.  In order
 to favor  the entrance of the lithotome as soon  as the membranous
 portion of the urethra is laid open, the operator directs the assistant
 to depress a little the plate of the  sound or depresses it  himself  in
 order to elevate its  concave portion behind  the pubes, at the  same
 time that he more or less inclines  the  wrist of his right hand down-
 wards.   By this means we run no risk of making a mistake, and the
 bladder escapes from any danger of being wounded.
  C. Process of Cheselden.—Morand, in describing the process of
  * F. Jacques did not die in 1713, as is asserted by Sabatier.  Havine arrived from
Rome at L'Etendonne, or, according to Normand, at his native town of Arbaene in
June, 1714, be went to pass several months at Besan^on, and afterwards remained a suf
ficiently long <; :ne among the Benedictines to build there a small house whicl he sub
sequently ab.ru!  v^d in order  to reside with his  friend L. Decart, where he <LcJ aired
69 years, and consequently in the year 1720, since he was born in the year 1651  ' 
LITHOTOMY.
577
 Cheselden, conveys nearly the same idea that Garengeot does, of the
 lateralized operation;  except that it would appear that  his principal
 object after having divided the prostrate, was to respect to a consider-
 able extent the other tissues, and to make a  wound  from the bladder
 to the perineum, similar  to a sort  of oblique canal, from behind for-
 wards.  Cheselden, moreover, has frequently modified his process of
 lithotomy.  His first method is the one which I have above described,
 while speaking of the  lateral operation,  and  his second method is the
 one which Morand made known.   The third, or the one which he
 finally fixed upon, is very different from the  ideas that are generally
 entertained of it in France.  The  English  surgeon gave  in  every
 case an extent of from two to four inches to his external incision, an
 incision which was made to fall  between the bulbo and ischio-caver-
 nous muscles, and to lay bare the urethra as far up as to the apex of
 the prostate.  The second stage of the operation comprised the inci-
 sion  of the deep-seated parts, exposed  to view by the first.  To ex-
 ecute this, Cheselden pushed the  anus with force to the right, and
 backwards, by means of his left  forefinger placed in the  posterior an-
 gle of the wound, then glided upon the  nail  of this finger a bistoury
 which was slightly concave, penetrated up to the neck of the bladder,
 while following the anterior side of the rectum, and came down upon
 the groove of the sound, when he divided from behind forwards, and
 from below upwards the whole extent of the  prostate gland, by  draw-
 ing his lithotome towards him, the cutting edge of which was turned
 towards the symphysis pubis.   The method of Cheselden is,  as we
 perceive, very distinct from the  oblique  or  lateralized operation, fol-
 lowed by the French practitioners.  It is  true that it divides the
 same parts  that Garengeot's does, but while it apparently puts him
 better on his guard against any  injury to  the rectum, it in reality
 creates only greater difficulties in the  manipulation.
  D. Boudou, who also performed the lateralized operation, and even
 before perhaps any person had described it  at Paris, made a process
 from  it which does not differ from  that of Mery, except in the  direc-
 tion which he gave to the  wound.   De la Faye  in  fact says,  in the
 additions he has made  to the treatise of Dionis, that Boudou inclined
 the plate of his sound towards the right groin, and that after having
 incised the membranous portion of the urethra, he plunged in the
 lithotome along the groove of the director, which was then raised up
 in the direction of the pubes, until he reached beyond the neck  of the
 bladder, and that he divided the  prostate  obliquely to the left, by
 bringing back towards him the cutting instrument.
  E.  Process of Le Dran.—Le Dran  also was desirous of having his
own process.  After having incised the urethra, he introduced a large
grooved sound into the bladder, and immediately withdrew the cathe-
ter, and terminated by  dividing the  prostate  with a convex bistoury,
which was a sort of a buckler-shaped instrument (rondache) guided
upon the  sound, and which was about six lines  in breadth.  Though
almost insignificant in itself, and calculated rather to embarrass than
to simplify the operation, this modification, nevertheless, has had its
partisans.   Schmucker (Bibl. Chir. du  Nord, p. 39,) says that no
patient will die from this  operation if it is well performed.  A. Bums
adopts the principle of this process, with this difference, that a bistoury
   vol. m.                   73 
578
NEW ELEMENTS OF OPERATIVE  SURGERY.
or ordinary lithotome appears to him to be preferable to the rondache
of Le Dran.  M. J. Bell, who is of the same opinion, incises from the
prostate towards the first  opening of the urethra, like Cheselden, in
the place of directing his bistoury from before  backwards, in the
manner of Le Dran ; and M. Allan, who, like his countryman also
directs the point of the "bistoury upon the sound, by passing  behind
the prostate, prefers to  withdraw the two instruments  at the same
time,  by holding them firmly against  each  other in the same way,
as is  very frequently done in the operation  for  fistula in ano.  It
would be difficult to discover in what manner lithotomy is rendered
more  convenient, or less dangerous, by these  various modifications of
the principal process.
  F.  Process of Lecat.—A mode of performing the oblique or  late-
ralized operation, which made some impression in its time, was that
of Lecat.   The sound of this operator terminated in a handle instead
of havino- a plate.  The instrument he made use of to lay bare and in-
cise the urethra, had a lateral notch  near its back, and received from
its inventor the name of uretrotome.  Lecat conducted, by means of
this last, another instrument terminated in a blunt extremity, into the
groove of the sound, in  order to cut through the prostate, nearly in
the same manner as in the second process of Cheselden, that is to say,
in the one described by Morand.  The  cutting edge  of this second
bistoury, however, which was called a cystotome, was never to go be-
yond  the vesical bourrelet, which is found at the entrance of the ure-
thra, for which reason precisely the name of cystotome was in no way
applicable to it.  Finally, the surgeon of Rouen had at one time the
idea of replacing his cystotome by a concealed lithotome. which he
denominated  a cystotome-gorget.  His axiom was a. small, deep inci-
sion, and a large exterior incision.   It is perceived that he already
foreshadowed the dangers of going beyond the limits of the prostate,
and that he preferred dilating rather than incising the entrance into
the bladder.  His method, which has  not been generally received,
though  he  obtained  unquestionable  advantages  from it,  neverthe-
less, continued to be adopted by some  practitioners.  Pouteau, who
had slightly modified it, obtained such decided success from it, that in
the hospitals of Lyons it is still employed quite frequently.
   A surgeon of Venice, M. Paiola, who has complicated it still more
by adding  another instrument to those  of Lecat, has, it is said, em-
ployed this process in 500 cases, and without losing a  single patient!
This assertion is so extraordinary, that  had  not Langenbeck spoken
of its author in  terms  of eulogy, it would not  have deserved the
slightest attention.  We perceive in the thesis of M. Dumont, that at
the hospital of Rouen, M.  Flaubert  also adopts the axiom laid down
by Lecat, and that in  his opinion a small incision with free dilatations
is a precept which the surgeon should never lose sight of.  Delpech
also thinks that there is less danger in dilating or even lacerating the
neck  of the bladder than  in  incising it extensively, and that iiTthis
respect Lecat's rule ought to be retained as  a law.  There is under
this precept an important truth, which  could not  be properly appre-
ciated until in these latter times, because the anatomical fact con-
nected with it had not been clearly indicated : it is this, that lithotomy 
LITHOTOMY.
579
confined ivithin the limits of the prostate is infinitely less dangerous
than that in which the incisions are extended beyond this gland.
   G.  Process of Moreau.—Moreau, a surgeon of the Hotel Dieu of
Paris, rejected all  these complications and performed the lateralized
operation in  the following manner.   His lithotome  resembled, to a
certain extent, the ancient lithotome of Collot.  He made an extensive
incision into the skin and sub-cutaneous cellular tissue ; laid open the
membranous portion of the urethra; elevated the sound  behind  the
pubis at the same  time that he plunged the bistoury into the bladder;
strongly elevated  the wrist of the right  hand, in order to incise  the
prostate obliquely, and afterwards depressed it, in order to replace the
cutting edge of his knife backwards at the moment when he brought
it out to the exterior.  Moreau's object was to have  a large opening
at the neck of the bladder, in order to extract the stone from it with
facility ; an opening still larger at the integuments, in order to prevent
infiltration or abscesses; and to incise but to a very small extent the
intermediate parts, in order that he might avoid  the arteries of the
perineum,  which  are chiefly found in that part, and  in order also to
respect the rectum ; so  that the wound in his operation would repre-
sent a double triangle, the strangulated  portion of which was at the
middle of its length.
   H. Process of F.  Cdme.—A modification of the  lateralized ope-
ration, which warmly interested the surgical world, is the one of
which Frere Come gave himself out as the inventor in 1748.  This
ecclesiastic had contrived an instrument  which,  being introduced
closed, through the incision of the urethra, into the bladder, was
opened by the pressure made upon  a movable piece at its outer ex-
tremity, and divided the prostate from within outwards, at the mo-
ment it was withdrawn.   This instrument,  which  has since been
known under the name  of the concealed lithotome, was at first sup-
posed to possess numerous advantages.  Its handle, cut into faces, and
numbered  by the  figures 5, 7, 9, 11, 13, 15, was arranged in such
manner, that by turning either of these figures towards  the movable
piece, we were sure of having a corresponding opening in the direc-
tion of its vesical extremity.   We thus know in advance  before in-
troducing it, and in a positive manner, that it will incise the neck of
the bladder, to the extent of 7, 9,  11, 13, or 15 lines, according as
we have  selected one or  another  of  the dimensions  indicated.
Franco speaks of an instrument of the same kind, and the concealed
bistoury of Bienaise  does not differ  materially from it.  The  objec-
tion made to it was,  that it was liable to  escape from the groove of
the sound, to slip between the bladder and the surrounding parts, to
wound the rectum at the  moment when  it is withdrawn, to  divide
the pudic vessels,  and especially to perforate the bladder itself as
soon as this has emptied  itself through the wound in the  perineum.  It
was to  remedy this last inconvenience  that Caquet, a surgeon of
Rheims, gave it a  blunt  point.  Moreover as it has, when rigidly ex-
amined, the advantage only of incising to a  determinate extent the
same parts that are divided with the other lithotomes, it has in  turn
naturally been both praised and rejected, and apparently with reason.
Those surgeons who are little practised in great operations, who are
not sure of their hand, and who are not perfectly acquainted with the 
580
NEW ELEMENTS OP OPERATIVE SURGERY.
anatomical relations'of the perineum, but who nevertheless dare to
perform lithotomy,  may, and  even ought to  give it the preference.
The lithotome gorget, formed  of two pieces,  which are movable on
each other, and which Bromfield proposed to  substitute for it, is infi-
nitely more defective.  As to the modifications  which have been given
to it by M. Evans of London, and  sundry operators in France, and
which relate almost exclusively to its handle and movable piece, they
are of too little importance, and too evidently matters of mere taste to
render it necessary  that I should describe them in this  place.
  I. Frere Come, down to the incision of the membranous portion of
the urethra, proceeded in the same manner as in the ordinary lateral-
ized operation.  The lithotome, directed on the nail of the  left fore-
finger into the groove of the sound, was immediately to be  introdu-
ced, shut up, into the bladder.  The surgeon then himself seized the
sound with his left hand, in order to depress its plate and to elevate its
concavity behind the pubis,  while with his right hand he pushed for-
ward upon the  groove of  the sound, the point of the concealed
bistoury, which  by this means  was  conducted into the  bladder.
The sound being now no longer necessary, was immediately  with-
drawn from the urethra.  After having again  satisfied  himself of the
existence of the  calculus, which may be readily touched with the ex-
tremity of the lithotome, the operator seizes the stem of this instru-
ment with his left hand, between the thumb and forefinger, in a state
of semiflexion;  opens  it by  making  pressure with his right  hand
upon the movable piece ; pushes its back firmly, and  a  little to the
right, against the symphysis pubis ; directs its cutting  edge back-
wards and to the left; withdraws it by elevating moderately its han-
dle, until its blade has passed  through  the prostate; loosens at this
moment its movable piece ; allows it to shut up again by degrees ;
and depresses it  more and more, and in  such  manner that, from the
neck of the bladder to the integuments, its cutting edge shall to  some
extent have circumscribed the half of a circle, the  convexity of
which would be  turned forward very nearly in the same way as in
the process of Moreau.
  J. Process of  Guirin.—F. Come is far from being  the only per-
son who has proposed a particular kind of instrument to diminish the
dangers of lithotomy.   Since  his time there have been  also a great
number of others contrived, the object of some of which has been to
give greater certainty to the opening into the urethra, and that of the
others to incise the  prostate or neck of the bladder with less danger.
Among the first  are to  be found various sorts  of sounds, that, for°ex-
ample, of  Guerin, which is  constructed in such manner that when it
is once introduced,  its outer extremity is  depressed to such extent
as  to face directly towards   its  most  convex  portion, that  is to
say, the groove  of  its urethral half.  This sound, moreover, termi-
nates in a sort of head which is pierced with a hole, through which a
long trochar grooved upon its lower side, may  be  introduced, and
which being directed upon the  perineum necessarily falls into the
groove of the sound itself without any danger of deviating  It is
perceived that the incision of the external soft parts then becomes a
matter of extreme facility, and that the  laying open of  the urethra is
no longer attended with the slightest degree of difficulty.  In other 
LITHOTOMY.
581
 respects the operator proceeds in the same manner as has been men-
 tioned in speaking of the median operation. • An instrument which
 hardly differs from  that of Guerin except in  being formed  of two
 halves, which are articulated by a hinge outside, has been introduced
 into practice  in  England by M. Earle, to effect the same object as
 that of the practitioner  of Bordeaux.   Deschamps proposes a third
 which also belongs to the same description, and M. Smith (Baltimore
 Aled. and Surg. Journ.,  April, 1832,) has  contrived a fourth which
 does not differ materially from that of Guerin.  If the opening into
 the urethra were really the difficult point in the operation, these kinds
 of sounds would perfectly carry out the intention.  But though the
 operator may have ever so little knowledge or skill, this is never the
 stage in lithotomy which embarrasses him.  Consequently the instru-
 ments of MM. Guerin, Smith, and Earle will continue to be, like so
 many others, a matter of taste and personal convenience. The ordi-
 nary sound, in which M. Chas. Bell  has placed the groove upon  the
 side, in order  to be enabled while leaving  it upon the median  line, to
 incise obliquely to the left on reaching  the prostate, is, in fact, only
 calculated  to  increase the difficulties  of  the  operation.  As to  the
 straight  sound extolled by  M. Zaviziano, (Mem. sur V Usage de la
 Sonde Droite, 1832,) or  the one which  is  but  slightly curved back-
 wards to the extent  of half an inch near its  point, like the one em-
 ployed by  M. Key, this  also does not  appear to me  to possess any
 real value or decided advantage over the others.
  K. Lithotomy with  the bistoury.—The instruments  devised with
 the view of rendering the opening into the bladder more easy and
 secure are  of  two kinds.  There are those, in  fact, which differ only
 by  slight modifications  from ordinary bistouries, while others, in
 reality, constitute special  instruments.   Thus the lithotome of Ches-
 elden,  which  is slightly  concave on its back, was modified by  A.
 Dubois  into a small knife with a fixed handle, but which in other
 respects  scarcely  differs  from  the convex  bistoury.  In England,
 Blizard made use of  a long narrow bistoury with a fixed handle, like
 that of the  French surgeon, and the point of which terminates on the
 back by a kind of blunt probe.  Klein, Langenbeck, Kern and Graefe
 in Germany each, also, have their own lithotome, which, like those
 above, are to be ranged in the class of simple knives or modified bis-
 touries ; but to whoever shall examine this matter attentively it will
 appear evident, that  all this is a mere optional affair, and that it is
 almost a matter of indifference whether we  adopt one or the other
of these  instruments, all  of  which might,  if necessary, be advanta-
geously replaced by  the simple or blunt-pointed bistoury.  It  is now
a long time also since Dupuytren, M.  Mott and a number  of  the
London surgeons made this remark, viz.,  that  the ordinary straight
bistoury is full as well adapted as the most  complicated lithotomes
for penetrating into the bladder, and for dividing in a proper manner
the prostate as it comes out, provided  it  is conducted  by a skilful
hand.  Dupuytren even  has performed lithotomy by plunging  the
straight bistoury by  puncture down to the groove of the sound and
then into the bladder, in  such manner as to divide at the same time
while withdrawing it, both the prostate and the entire mass of tissues
 which form the perineum.  This process, which assimilates lithotomy 
582          NEW ELEMENTS OF OPERATIVE SURGERY.
to the simple opening of an abscess, is more easy than is  supposed.
I have frequently madte trial of it upon the dead body while going
through the operations before the  students:  but as it cannot have, in
reality, any other advantage than that of abridging the operation by
the space of about half a minute, I do not think that prudence would
allow us  to  establish a manipulating display of this kind as a law in
surgery.   If, however, we should decide upon using  a simple bis-
toury, we should open the urethra in the ordinary mode, and after-
wards glide the instrument upon the groove  of the  sound, by pro-
ceeding in the same way as with  the other kinds of  lithotomes.   It
would be in such  cases that my  double sound  with an eye would
be applicable.   The special instruments which remain  to be spoken
of are known under the common title of gorgets.
  L.  The  process  of Hawkins.—The first  gorgets  employed in
lithotomy were nothing more than a simple  gutter terminated at one
end by a probe or button, and  at the  other  by a kind of handle.
They were made use of to replace the sound, and are also employed
in almost every kind of lithotomy in order to give greater facility to
the  introduction of  the tenacula.   Under this  form they have blunt
rounded borders, in order not  to incur the risk of wounding the parts.
It was not until about the middle of the last century that Hawkins,
an English  surgeon, suggested the idea of  transforming the gorget
into a lithotome, that is to say, to give one of its borders a cutting
edge near the point.   This instrument, which most English surgeons
adopted, is employed in the following manner: As soon as the sur-
geon has  opened through the membranous portion of  the urethra, he
seizes the gorget by its handle and applies its button into the groove
of the sound and pushes  it into the bladder, taking care that it does
not  let go  its  hold  upon the last mentioned instrument, which, by a
vibratory movement, is to be  raised up behind the pubis, in propor-
tion as the gorget divides the left side of the prostate.   The apparent
simplicity of Hawkins's gorget did not prevent its partisans themselves
from noticing its defects.   Bell, perceiving that its blunt portion was
too  large, made it small in order to  prevent  it from lacerating or
contusing the parts.   Desault dispensed with its concavity, placed its
button altogether to the right and  upon its blunt border, and in other
respects  adopted the modification of Bell.  Blicke,  fearing that it
might escape from  the sound and get in between the rectum  and
bladder,  instances  of which MM.  A. and S. Cooper state that
they  have  frequently been witness to,  arranged the button in such
manner that it could not escape until it had arrived  near  the
extremity of the groove of the sound.  That of Abernethy, so to
speak, resembles a triangular  gutter, as is noticed also in the gorget
of Cline,  or a semi-cylindrical canal  like that of Hawkins.   Dorsey
has given the figure of one, the blade of which, which can be easily
detached, has  in every part of  it the same  width, and  the free
extremity of which, cut obliquely like that of Desault's kystotome, is
the only part which  has  an edge.  Finally, Scarpa, who avowed
himself a partisan of the gorget, has gone to  a great length to demon-
strate that it ought to have a very narrow cutting edge of the extent
of two lines near its button,  becoming gradually wider until  it has
acquired  a transverse diameter of about seven lines, and that  this 
                           LITHOTOMY.                        583
                      •
 cutting edge ought to be bent into an angle of sixty-nine degrees to
 the  border which  constitutes its back, in order that while  cutting
 through the prostate, it may make in this gland  a wound, whose
 angle should also be sixty-nine degrees, in  relation to the axis of the
 urethra.  Some English surgeons,  among others Dease and Mair,
 supposed that there would be greater security given in the employ-
 ment of the gorget by making use of Le Dran s sound for its director;
 but  this proposition has not had and could not have any advocates.
 In France the gorget has found but a very small number of admirers,
 and M. Roux is almost the only person who makes use of it in Paris.
 The most  simple reflection  will be  sufficient to show the  little
 importance, I  might say almost the insignificance, of the various
 modifications which it has undergone.  It is the gorget as a  special
 instrument, and not the gorget in particular, which is the important
 one to be  examined ; and I am surprised that authors of so much
 repute  should  have wasted so much  time in discussions relating to
 this subject.  It is certain that with the gorget we never can  wound
 the  rectum  or pudic artery, unless there should exist some anatomical
 anomaly; and also that we cannot  go beyond the limits of the pros-
 tate.  But  as the only reason of these advantages  lies in the small
 extent given to the incision, it is clear that we could obtain the same
 result from  any lithotome whatever, provided we restricted ourselves
 to a wound of from six to seven lines.   Its inconveniences are that
 it always makes a passage of the same width whatever be the vol-
 ume of the  stone; that it exposes more than any other instrument to
 the  danger  of wounding  the  posterior wall of the  bladder, or even
 transfixing this organ, as M. Earle says he has seen, and  especially
 of dividing  the tissues by pushing them before it, and by separating
 the different layers of the perineum from one another, of relaxing
 them to some extent in the place of stretching or pressing them from
 above downwards, in  the  way  for example it is done by the  con-
 cealed lithotome, and by almost all the  cutting instruments made
 use  of by different surgeons in this second stage of the operation.
 Finally, that it dilates and contuses at the same time that  it divides,
 that it obliges  the operator to have several of different dimensions,
 and  that it  does not allow of  an incision of more than eight  to nine
 lines in extent.   One of its advantages, perhaps, which is  the most
 positive though it has not been noticed, is to be found in the direction
 which it gives to the  incision of the prostate, an incision which is
 semilunar, the convexity of which is turned backwards and  to the
 right, and the are of which having a cord of about  seven lines, may
 be enlarged  without laceration to the extent of two to three lines,
 when we proceed to elongate it  while  extracting the  calculus.
 Under this point of view the gorget of Desault is evidently the least
convenient of all; for to attain the object in view it  would be neces-
sary, while increasing its breadth at the cutting part, to preserve its
primitive gutter-like or semi-cylindrieal form.   In this respect, more-
over, it would no longer be applicable to the lateralized or oblique
operation, properly so  called.  The incision would  be rather trans-
verse than in the direction towards the left ischium; from whence
 would arise another inconvenience, since we should incise upon  a
segment of the  prostate, which  would  be less in length  than that 
 584           NEW  ELEMENTS  OF OPERATIVE  SURGERY.

 which would have been incised in the process of Frere Come, Che-
 selden or Garengeot.
   M. Process of Thompson.—The deviation  from the line originally
 contemplated for the lateralized operation, is  however not the only
 one which  has  been proposed.  In  1808, Thompson also, with the
 view  of avoiding the rectum and perineal arteries, suggested that we
 should incise with the ordinary lithotome, not downwards, but in fact
 upwards, and a little  to the  outside, provided  an incision of some
 lines backwards should not be found  to be sufficient to allow of the
 extraction of the stone.   Nearly about the same time, Dupuytren, for
 the purpose of avoiding the same organs, deemed it advisable to car-
 ry his incision almost directly upwards ;  that  is*to say, having arriv-
 ed into the bladder, he turned  the cutting edge of his bistoury, or  of
 the lithotome of F. Come, upwards, and a little to the right, and par-
 allel to the  ischio-pubic branch of the pelvis, as if for the purpose of
 reaching up to the symphysis.   M. Pantaleo, (Gaz. Aled.,  1834,
 p. 411,) who incises the  prostate posteriorly, and to the left, and then
 in front and to the right, has in reality done nothing more than to repro-
 duce  the suggestion of Thompson.   These modifications have had
 to be abandoned, even  by their authors themselves, since in  such
 processes we divide the prostate in that direction where it has the
 least diameter, and that we almost unavoidably go beyond its limits,
 and for the still greater  reason, that  we  are  obliged  to extract the
 calculus at  a narrower part of the lower strait than  in the posterior
oblique operation.
  N.  Process of Boyer.—Boyer, who almost always used the  con-
 cealed lithotome, and who was considered very fortunate in his ope-
 rations for stone, did not make his incision in the direction of any of
 those  lines which  have been above indicated.   In place of resting the
 back of his instrument against the symphysis, he held it firm against
 the right ischio-pubic branch,  so as to be  enabled to direct its cutting
 edge almost entirely transverse and to the left while withdrawing it,
 and to divide the prostate from within outwards,  in the same way as
 every person does.  When we proceed  in this manner, we run no
 risk of wounding the rectum or pudic artery,  any more than we do
 the transverse artery, whose course is nearly parallel to that of the
 incision, so that the superficial  artery is in reality the  only one which
 could be in any danger.   A modification  of this  kind would be  free
 from all objection, if we were not obliged to divide the prostate  in
 the direction of one of  its shortest  diameters, or if it were possi-
 ble to give  an extent of more than 7 or 8 lines  to this division with-
 out going beyond the circumference of  the gland.   The lithotome
 directed in  this manner, presents  in  fact all the advantages  of the
 gorget, without being attended with its inconveniences.
  O.  The Author.—If it be true, that the question to be solved in the
 oblique operation for stone, is  that of dividing  as extensively through
 the prostate as possible, without passing beyond its periphery, the incis-
 ion directed downwards and outwards, is evidently the only one which
 ought to be adopted.  According to  this hypothesis,  the process of
 Thompson, and that which Dupuytren was desirous at one time of in-
 troducing into practice, would  no longer be worthy of any consider
 ation.  The rule adopted by Boyer, which allows  the cutting edge 
LITHOTOMY.                        585
of the bistoury to be inclined a  little towards the ischium, is infinitely
preferable.  For the extent of a line perhaps, that it  makes  us lose
at the place where the prostate would be opened, we procure in com-
pensation incontestable advantages in relation  to the rectum and ar-
teries.   As to the incision made after the manner of Boudou, Garen-
geot, Morand, Le Dran, Moreau, Dubois, and J. and Ch. Bell, or after
all those in fact who prefer the bistoury to particular lithotomes, and
whose object is to make a large opening into the neck of the bladder, it is
a matter almost of indifference whether we imitate one or the other, so
long as we take care to give a sufficient extent  to the incision through
the integuments and the other  tissues composing the perineum.  The
method of Lecat presents two points for consideration:  1st, the in-
struments which the  inventor  made use of, and which may be re-
placed by  an infinite number of others ; 2nd, the suggestion that we
should make only a small incision in entering into the bladder.  It is
under this point of view only, that the  operation of Lecat is worthy
of being distinguished.   De la Motte  had  already maintained that
there is less danger  in  dilating or even lacerating, to a certain ex-
tent,  the  entrance  into  the  bladder,  than by incising it.  More-
over, the justice of this position can  scarcely  be called in question.
The error of those who have defended it, is  that of not having com-
prehended its  fundamental principle, and of having given too extrav-
agant an extension to  it.   In fact the  small incisions mentioned by
Lecat have no other advantages over  the  great ones, except that
they enable us to restrict ourselves to the  periphery of the prostate,
from whence it follows  that the other  operations would not  expose
us to any more danger, provided that we did not go beyond the con-
tour of this gland.   I have mentioned above, what estimation is to be
placed on the gorget and  its different varieties.  There remains to be
considered, the instrument of Frere Come, which, it cannot be denied,
offers in  reality a great  degree  of security, an  extreme simplicity in
its construction, and the  advantage that  it can be employed  with
more facility than the bistoury, by the  greater number of operators.
As the principal dangers of the oblique operation are the lesion of the
rectum, of the pudic artery, and of the transverse or superficial arte-
ries, all the instruments, with the  exception  of the gorget, are under
this  point  of view attended with nearly the  same inconvenience.
Provided we can satisfy ourselves in respect to the condition of the
intestine, by introducing our finger into it, and that we have taken
care not to give  too great  dimensions to the deep  portion of the
wound, and have conducted the lithotome with some adroitness, we
shall not wound it.   As  the pudic artery is  always situated upon
the contour of the pubic  arcade, and consequently considerably be-
yond the limits  of the  prostate, it does not in reality run any risk
of being wounded.  As the superficial artery has its  seat in the
sub-cutaneous  layer, it  could  be too easily seized, twisted,  tied or
cauterized  to make its division  a matter of  any apprehension.  The
transverse  artery of  the  perineum, which is ordinarily quite small,
will  not  be avoided with certainty, unless  the incision of the ure-
thra  should not  commence too near the bulb or too far from the
prostate.   Fortunately the hemorrhage which results from it is rarely
sufficiently abundant to  be a matter of serious importance.  It can
   vol. in.                      74 
586
NEW ELEMENTS OF OPERATIVE SURGERY.
only be, therefore, in  cases of anomaly or deviation in the direc-
tion of these vessels, or of their preternatural size, where any danger
can exist under this point of view, in practising the lateralized opera-
tion.  A more serious difficulty by this method, is that of being only
enabled to obtain an opening at most  of from ten to twelve lines,
and which is  consequently too small  to allow of the extraction of
large sized calculi.  It was  with a view of remedying this real in-
convenience,  and independently of all processes and all operators,
that the following method has been warmly approbated.

    §  IV.—The Transverse  (bi-lateral or bi-oblique) Operation.

  Another interpretation of Celsus  has given rise to a new operation
in lithotomy.   In speaking of  the  extraction of calculi, the Roman
author recommends that we should make  juxta anum, cutis plaga
lunata,  usque  ad cervicem vesicae, cornibus ad  coxas spectantibus
paululiim, and then that the  instrument must be brought back to the
bottom  of this first wound,  in order that we may make  another,
which is to be  transverse, and which opens the neck of the bladder
in penetrating  down to  the calculus.  Now it is this passage, hitherto
explained in such manner as to refer to it the origin  of the lateral
operation, and the lateralized operation as  well as  the little one for-
merly described by the Greeks  and  Arabs, which,  when  brought
back to its legitimate signification, has suggested the idea of the new
method.   The expressions plaga lunata and plaga transversa had,
it is true, in more than one instance embarrassed the commentators
of Celsus ; but in putting the singular in place of the plural, and by
translating ad coxas as towards the thigh (vers la cuisse), they sup-
posed that they had overcome the difficulty.  It was in vain that Davier
made Cochu sustain, on the 15th April, 1734, at the  Faculty of Paris,
that in the operation of Celsus, we  are  to make upon the skin near
the  anus an incision in the  form of a crescent,*the extremities of
which are to be turned towards  the thighs; that  Heister made Us-
mand  repeat  the same phrase, in November, 1744;  that Normand
de Dole, who complained, in 1741, of the little attention paid  to the
reading of the  ancient authors, recalled to mind that in the operation
of Celsus,  the incision, which was of a crescent form, should have its
horns turned slightly towards the thighs of the patient, and that the
same  interpretation was again  given  by Macquert  in  the  thesis
which he supported in April, 1754, by Portal in his Precis de Chi-
rurgie, published in 1708, and  by Deschamps himself, in his treatise
on stone ;  nobody took the trouble to  derive the slightest profit from
it.  A second difficulty which  Bromfield had in vain endeavored to
remove, had undoubtedly been the reason.   This was to ascertain if
the  words cornibus spectantibus paululiim  ad coxas ouo-ht to be un-
derstood to mean a semilunar wound, whose  extremities  should  be
turned forwards rather than backwards.  All the  authors  whom I
have just  quoted  have, as we perceive, adopted  the  first  version
Bromheld alone inclined to the second, which appears in fact to  be
the  true signification, inasmuch  as the word coxas among the an
cients was generally applied  to the large bones oft the pelvis and to
the  ossa ischia m particular.  However this may be, it was not until 
LITHOTOMY.
587
 at the beginning of the present century that the question was exam-
 ined in a correct point of view.
   In the year 1805, M. Morland recalled in his thesis the trials made by
 Chaussier on this point, essays by which it was proved that a semilu-
 nar incision, with its concavity posteriorly, would enable us to enter into
 the bladder and to extract the calculi from it.   Nevertheless, it was
 still labor lost.   Chaussier himself had forgotten his own  researches,
 when  in 1813 Beclard reproduced them almost  in the same terms as
 M. Morland, and  with  full  as little success.  The cogent and en-
 tirely  conclusive arguments adduced in 1818, by M. Turck, in  favor
 of the same  principles, did not any more succeed in changing the di-
 rection of the  public mind.   But in 1824, Dupuytren, whose atten-
 tion was occupied with the  subject  of rendering lithotomy less dan-
 gerous,  having had the same idea  as  Chaussier, Beclard, and M.
 Turck, and  almost  immediately making an application  of it  upon
 living man, was soon convinced that this method contained a precious
 process  for  the operation of  stone.  Beclard, without attaching  so
 much  importance to it, and  who moreover had never overlooked it,
 but, according  to M. Olivier dAngers, had occasionally already used
 it in  practice,  again  described its advantages before the  Academy,
 while  Dupuytren, at the Hotel Dieu, demonstrated its extreme value.
 Since  that epoch, a great  number of surgeons have adopted it, and it
 is now reckoned among the best methods.
   A. Process of Chaussier.—We perceive by the thesis of M. Mor-
 land, that Chaussier,  after the mode of M. Ribes, began  by incising
 all the soft parts between  the anus and the  bulb  of the urethra, with
 the point of a  scalpel; that he had had the idea of a  sound with
 a double groove, one  on the  right and the other on the left, in  order
 to be enabled to divide the  membranous and prostatic portion of the
 urethra, on one side only,  or on both sides in succession,  should the
 volume of the stone appear  to require it; that in his opinion a
 grooved  sound  could replace this instrument, provided that by  intro-
 ducing it into the wound, it would be easy to incise upon it to the left
 and then to the right; that he also had had the  idea  of a concealed
 lithotome with  a double blade, and of the sheathed scalpel of Louis ;
 but that he took care to make the remark, that in such cases, the best
 of instruments  was the mind, guided by  an exact knowledge of the
 situation and nature of the part.
  B. Process of Beclard.—The instrument which Beclard selected
 is a sort  of gorget of some  breadth, slightly concave, cutting  upon
its two edges, and terminated in a tongue in the direction  of its  con-
vexity.   He  also speaks of the double lithotome, leaving   every one
at liberty to  adopt it or to dispense with it.   He finally had made,
in order  to carry  out the same indication, a knife  of a sage-leaf
form, and nearly similar to the  lithotome of Cheselden.  He  incised
the skin  and the other tissues, moreover,  in the  same  manner  as
Chaussier.
  C. Process of Dupuytren.—Dupuytren,  for  the purpose  of per-
forming  the  transverse operation, contrived two  particular instru-
ments ; first,  a  fixed bistoury, or sort of scalpel with a cutting  edge
on both sides near its point,  to  the extent of some lines; second, a
double lithotome, which might have been suggested by a phrase in 
588
NEW ELEMENTS OF OPERATIVE  SURGERY.
 Franco, and which is very accurately represented by the cutting te-
 naculum of Tagault, figured at page 366 of the additions of Joubert
 to the work of Guy, printed in 1649 ; one which Fleurant had men-
 tioned,  in  speaking  of lithotomy in women, of  which.  Lombard,
 Thomassin,  Corps Etrang., &c, p.  103, 1788,) has given  the  de-
 scription and figures, which Chaussier and Beclard had also  thought
 of, but which  it was reserved for Dupuytren to  bring into repute
 and to render as simple as possible.   M. A. Stevens and M. Amus-
 sat, finding it  still too complicated, have  proposed to employ in its
 place a sort of scissors, with  cutting edges  on their borders when
 opened, but which are blunt when shut; but  these scissors  are not
 capable of fulfilling  all the indications which we have in view in
 making use of the double lithotome.  It is not in fact a simple trans-
 verse incision  which the surgeon ought to think of making, but this
 incision should at the same time  be oblique in the direction back-
 wards and outwards on each side, in order that it may embrace at
 once the two  largest  portions of the prostate.  Dupuytren, who had
 early felt the necessity of this, has  found everything that he could de-
 sire in this respect, in the modifications which M. La Serre, and espe-
 cially those which the ingenious cutler M. Charriere has given to his
original lithotome.  Finally, in place of the ordinary sound, Dupuytren
has contrived one which is dilated, as it were, at its greatest convex-
ity, in order that it may make greater distension upon the urethra, and
the groove  of which is more flaring and has less depth at its extrem-
ities, than in its middle portion.   The patient is arranged in the same
manner as  in all the otherv operations  for lithotomy.  The surgeon,
placed in front of the perineum, stretches  the  integuments with his
left hand.   With a scalpel  in his  right hand,  he makes the semilunar
incision;  commences it  near  the right ischium ;  extends  it to six
lines in front of the anus, and  terminates it on the inner side of the
left ischium, in order  that its horns may fall on the middle point of
the space, which on the  right and on the left  separates the anus from
the tuberosities of the ischium.  He thus divides  in  succession the
 different layers which present themselves, keeping rather on the me-
 dian line, until he arrives near the membranous portion  of the ure-
thra, which he divides longitudinally.  Then laying  aside the scal-
 pel, he  takes the lithotome,  whose  handle has   been previously
 fastened at the proper  degree, and directs the point  of it upon the
 conducting instrument, with its concavity turned upwards, in order
 to introduce it into the  bladder in the same way as when we make
 use of the  instrument  of  F. Come.  Before  opening it, it is to be
 made to circumscribe a  half circle, in order that its concavity, which
 was turned upwards,  may now look downwards towards the rectum.
 It is then to be opened, after which it is  to be withdrawn  in the di-
 rection of the  external wound, after having embraced it  with the
 thumb and forefinger  of the  left hand  a little beyond its  handle
 while with the right hand we keep it open, in order to  divide from
 within outwards the prostate and  the soft parts, which had been re-
 spected by  the scalpel.
  There can be no doubt  that the  ordinary bistoury might  in  this
 operation be made to answer  perfectly well in place of the scalpel •
that the lithotome of F. Come, directed first to the left and afterwards 
LITHOTOMY.
589
 t6 the right, may serve to incise the same parts; and that the double
 cutting-edged  gorget, which  Physick had  already  made use  of in
 1804, which M. A. Cooper  also sometimes employs, and  which Be-
 clard has proposed, might also  be  very well adapted to effect this
 double incision; even the simple strait probe-pointed bistoury might
 in a case of necessity be substituted for all those instruments for divi-
 ding the prostate.  But we cannot  deny to the double lithotome the
 advantage of terminating the operation with a single cut, that of ef-
 fecting a more certain tension of the parts in proportion as it divides
 them, of giving a. greater degree of regularity to the wound, and es-
 pecially  that of making an  actual curved instead of  a simple V inci-
 sion, which latter is the only one which can reasonably be expected
 if we use the bistoury or other lithotomes.  Reason immediately sug-
 gests to us the important  character of this method.   Should  each
 blade of the lithotome be separated to the distance only of four lines,
 there would evidently result from this a wound of at least 8 lines, or
 even 10  lines, if we include the calibre of the urethra.  Now since
 each oblique posterior portion of the  prostate has nearly  10 lines in
 diameter, it is perceived that we  may thus give to the wound as
 much as 20 lines in dimension.  Moreover, if the incision accurately
 represents a  curve, the  tractions  made upon it in our efforts to
 straighten it, will elongate it still more ;  and the posterior portion of
 the prostate being crowded back with the rectum, while we are en-
 deavoring to  extract the stone, will be  readily transformed into a
 second curve  parallel to the first, so that a calculus of 20 to 24 lines
 in thickness, and from 5 to  6 inches in circumference, might, strictly
 speaking, pass through  this opening without causing any laceration.
 None of the ancient methods of perineal lithotomy can be compared
 in this respect with the  transverse operation.  As it  incises the tis-
 sues to the outside, and slightly backwards, it cannot endanger the
 intestine, except in cases where this  latter  is enormously distended
 on each side of the bas fond of  the bladder, and then only when we
 are obliged  to open the lithotome to  a  very great extent.  The pu-
 dic artery is also protected from any kind of lesion.   The same may
 be said of the  superficial artery in all cases where it occupies its nor-
 mal position.  So also with the transverse artery, which can be but
 rarely wounded, for the most  advanced point of the incision must be
 behind the bulb of the urethra, to which part it is found to be princi-
 pally distributed.   The  only arteries therefore that can be wounded
 are the posterior branches of this last mentioned vessel, when  they
 are .larger than usual near the anus, and the anterior  divisions of the
hemorrhoidal artery.   As the first incision comes down upon the
membranous portion of the urethra,  and as the  two blades of the
lithotome are first obliged to act towards  the outside, the verumon-
tanum and the ejaculatory ducts are  necessarily protected from every
kind of danger.  Nevertheless, it is not  to be forgotten, that in some
persons, the lower dilatation of the rectum is prolonged to below the
prostate,  and that if we should make  the incision too near the anus,
we might readily perforate this intestine at the first stage of the ope-
 ration, as it is  said happened in  one instance to Dupuytren himself.
 A danger which reason  would have enabled  us to have apprehended,
is that  of a  urinary fistula,  It would seem  at  first view  that so ex- 
590
NEW ELEMENTS OF OPERATIVE SURGERY.
 tensive a wound of the posterior and  inferior wall  of the urethra,
 must be little calculated either for immediate or consecutive reunion.
 Experience, which is the only competent judge in such matters, has
 not confirmed these apprehensions.   On the contrary, it goes to show
 that as a general rule, the urine resumes its natural  course  more
 speedily after the bilateral operation than after any other.  They
 count at the Hotel Dieu as many as 26 patients operated  upon by
 this method, without a single one of them terminating fatally ; out of
 an aggregate of 70 mentioned by Dupuytren, there  were  but  6 that
 perished.   If, in respect to the accidents, it is not better,  it  must at
 least  be confessed that  it is full  as good as the other processes.  To
 derive all the advantages possible from  it,  the incision, it  would ap-
 pear to me, ought to fall upon the base of the uretro-anal triangle, in
 such  manner as to avoid, at the same  time, both the anus and the
 bulb,  and  afterwards to  arrive at the posterior part of the membra-
 nous  portion of the  urethra, a little in  front of the  prostate,  after
 having divided through the integuments, the sub-cutaneous layer, the
 mixed fibres of the sphincter of the anus, the bulbo-cavernous and trans-
 verse muscles, as well as those of the aponeuroses at the point where
 they are blended together.  It is necessary also that the horns of
 the incision should be sufficiently prolonged in the direction  towards
the ischio-rectal cavities, to prevent their presenting any obstacle to
the escape of the discharges externally.   If the bilateral  operation
 did not admit of as prompt a cicatrization as the incision on  one  side
 only of the prostate, it would without doubt, as Beclard considered
it and as Scarpa  maintains in  his  letter to  M. Ollivier,  constitute
nothing more than  an  exceptional method, useful  only in  cases
 where the calculi were exceedingly voluminous ; but  since  the con-
trary  is the fact, I cannot see what should  prevent it from  bein»
 adopted as a general method.
  D.  Process of 31. Senn.—M.  Senn, a surgeon of Geneva, has en-
 deavored  to prove, that in place of performing the transverse ope-
 ration with the double lithotome, it is better, by means of the  straight
 probe-pointed bistoury,  to  divide at first only one  of the  oblique
 portions  of the  prostate, and that should the stone seem to be of
 too large a size, we should then  incise this gland transversely to the
 right, with a second cut.   Upon  the strength of geometrical  data, he
 asserts  that the triangular flap  thus circumscribed  at  the  expense
 of the urethra and the gland through which it passes,  and  the base
 of which  flap is posterior, and  to  the  right, procures when  it is
 stretched  or pushed back towards the rectum, at the time of extract-
 ing the calculus, a greater opening than  by the process of Dupuy-
 tren.   The process of M.  Senn differs from that which Thomson re-
 commends m cases of large calculi, in  this  particular, that one of
 his  incisions is  to the  right, and  the other to  the  left,  while  the
 English surgeon made them on the same  side,  one above  and the
 other below.   In  my judgment it possesses the inconvenience of
 being more tedious, and somewhat less certain than the operation
 by the double concealed lithotome, without having any real ad van
 tage over  this  last   Martineau of Norwich, had  already laid  it
 down as a rule, and Louis himself had also recommended  it  that we
 should, when we experience any difficulty in extracting  the  stone 
LITHOTOMY.
591
introduce the  finger into the bottom of the wound, for the purpose
of ascertaining the point which makes resistance, and then proceed
by  means of  the bistoury to enlarge the incision either backwards,
upwards or outwards, as was practised with  so  much success  by
Saucerotte ; from whence it follows that there  is no portion of the
prostate which will not have been incised by either one or the other
of the processes, for the lateralized or oblique, or  transverse opera-
tion, as the  same have been modified  by Louis, Martineau, Boyer,
Thomson, Dupuytren and M. Senn.   From this circumstance even,
there has originated a new mode of performing lithotomy.

               § V.—The Quadrilateral Operation.

  The necessity of not going beyond the limits of  the prostate while
enlarging the  entrance of the urethra, and of obtaining, nevertheless,
an opening as large as possible, has induced M. A. Vidal, who had,
he  asserts, made investigations on  this subject at the hospital  of
Marseilles, in  the year  1825, to propose that we  should incise this
gland upon its four principal portions, that is to say, on both sides
posteriorly to  the  left,  and posteriorly to the  right, and obliquely
forwards.  According to M. Vidal, this quadruple incision might be
made with a single  cut,  by means of a four-bladed  lithotome ; but he
prefers using a simple bistoury, carried  successively in the  four  di-
rections  indicated.   The  reason for this preference is, that if the
calculus  is but  of  little volume, the surgeon may at  his  pleasure
incise only one, two or three portions.  His method has been  followed
at the hospital of Aix, by M. Goyrand, who asserts that he has been
well satisfied with it.  I have myself had occasion to put it to the test
in a patient in whom the calculus had two and a quarter inches in its
principal diameter.   The patient was a man 69 years of age.   I ope-
rated at first by the method of F. Come, and it was  not until after
having recognized  the impossibility  of extracting the calculus with-
out lacerating  the  parts, that I had recourse to the process  of  M.
Vidal, modifying it  however in the following manner:  In order not
to be obliged to let go the stone, an assistant took charge of the
hooks in which it was  grasped, and held them up slightly  elevated
towards  the left side.   A straight probe-pointed bistoury guided up-
on  the forefinger, enabled me to incise the posterior right portion of
the prostate, after which I did the same to the transverse portion, at
some lines  above.   The operation was  followed with  complete
success.  In adopting this process, each incision may have only two
or three lines  of extent, and yet their  aggregate, nevertheless, will
furnish an opening  of nearly an inch.  If we should give them four
to five lines in extent, it is immediately perceived that we shall have
a passage of from 15 to 20 lines in diameter, and that under such circum-
stances we would obtain a track for the largest description of calculi,
without running the risk of going beyond the periphery of the prostate,
or of wounding the rectum  or  any of the  arteries of the perineum.
Should the bilateral  operation prove insufficient or create any danger,
the suggestion of M. Vidal  would then offer us  a  resource  which it
would be important not to  neglect.   Upon the supposition that  we
should decide  at first in its  favor, there would, in  my opinion, be an 
592
NEW ELEMENTS OF OPERATIVE SURGERY.
 advantage  in  making  use  of  the  four-bladed lithotome which M.
 Colombat has had made, rather than to make the four incisions in suc-
 cession with  an ordinary bistoury, and  this for the same  reasons
 which render the double lithotome  preferable in the simple bi-trans-
 versal operation.  It is important moreover not to forget that M. Vi-
 dal incises the prostate in the direction of its oblique portions, and not
 from before backwards  or transversely,  as has been erroneously
 stated.

     § II.—The  Operative  Processes in Perineal  Lithotomy.

   A.  The  different Articles.—Before  commencing  the  operation
 the surgeon ought to arrange in order all  the articles which  may be
 needed, whatever may be the  process upon which he has decided.
 These articles are: 1st, silver catheters and sounds, or such as are of
 gum-elastic should they be  required; 2d, a common  straight and a
 convex bistoury, the curved  bistoury of Pott, a straight probe-pointed
 bistoury,  one  or more cutting gorgets,  and one of the  lithotome
 knives mentioned above, if we have the intention of using them;
 3d, the concealed lithotome of F. Come, opened  at  number five or
 seven for  children, and at nine or eleven, but rarely thirteen or fifteen
 for adults; 4th, the stem and the button  scoop having a crest on its
 flat side;  5th, a simple  gorget;  6th, straight and  curved tenacula of
 various dimensions ; 7th, long polypus forceps,  dressing forceps, dis-
 secting  forceps, and  straight and  curved scissors; 8th, the needle
 having a handle used by J. L. Petit, or that of  Deschamps, together
 with  common  ligature  needles;  9th, a simple canula of  metal or
 gum-elastic, another  canula provided with its cover, rolls  of lint
 encircled  at their middle portion by a  noose  of strong and  well
 waxed thread; and 10th, small balls of lint and coarse lint, a  few
 bandages  and  compresses, lithotomy bands, water,  sponges, some
 styptic liquid, a strong syringe, and  finally, one or more wax candles
 if the natural light does not appear to be sufficient.
  I.  Sound.—Among these articles  there are some, the selection of
 which requires particular attention, viz.:  the sound and the tenacula.
 All other  things being equal, the sound should be rather large in size
 than too small.   The more volume it has  the better it distends the
 urethra, the easier is it  to feel it at the bottom  of the perineum the
 more advantageous does it become  as a director of the other instru-
 ments, and the less danger will  the  patient have of being wounded.
 Its groove ought to be  at the  same time wide and deep; otherwise
 the finger will have  difficulty in distinguishing  it through the walls
 of the urethra, and the lithotome will be unable to be directed by it
 with a sufficient degree  of accuracy.  It is a matter of little import-
 ance afterwards whether we give its transverse  portion the semi-
 lunar form which it  formerly  had, the triangular shape which is
generally  preferred  by the English surgeons, or the square  shape as
recommended  by Dupuytren.   As the cul de sac which  terminates
it is but of doubtful utility, and  must be calculated to interfere  with
the movements of the point of the lithotome, it ought to be divested
of it, but  in a gradual,  manner, in order to preserve a rounded  and
blunt arrangement to the sound.  Were it prolonged to the extremity 
LITHOTOMY.
593
of the instrument it would possess no advantages except in the pro-
cesses where -the  sound is to remain £xed, and not to be raised up
towards the pubis before the division  of the prostate,  because  in
such  cases  the point of the bistoury is more firmly secured by it.
The curvature of this instrument moreover need not extend as far as
its extremity, which latter ought to  go  an inch or two beyond the
axis of the  handle, if we do not wish to run the risk of its receding
into the urethra when we suppose it  to be still in the bladder.  It is
unnecessary to add that the form of its plate is a mere matter of
taste, and that in  terminating it in this  direction with a ring in the
manner of  Pouteau, or by a stem provided with  a wooden  handle
like that  of Lecat, &c, we render it  neither more nor less con-
venient.
   II. Tenacula.—The ancient tenacula, which were  articulated like
scissors and very  near their branches, possessed the double inconve-
nience  of opening  more extensively in the wound than in the bladder,
and of grasping the calculus with difficulty.  It did not prove suffi-
cient to place the rings on the outer side of the handles; but in order
to remedy this defect these last were arranged in  such manner that
they more or less  cross each other inwardly, and  that before  going
past the axis of the instrument outwardly they allowed the branches
to open to  a considerable extent.   Those whose branches remain
parallel in  the place of separating,  while diverging when  they are
opened, and which are  articulated laterally, like those found  at M.
Charriere's, have moreover the advantage of not losing their grip so
readily, and of adapting themselves better to the form of  the stone.
   III. Position of the patient and  of the assistants.—An  ordinary
bed is too large and soft, and in general too low to take the place in
private practice of the operating table, used in public establishments.
Nevertheless, I am  not  friendly to  those  mechanical contrivances
that certain persons are so much in the  habit  of transporting to the
chambers of the sick ; under this point of view, the  table of M. Heur-
teloup,  that  of M. Tanchou, M. Rigal, &c, however ingeniously con-
structed they may be, do not appear  to  me to be any more  indis-
pensable than M. Rouget's bed, or the lithotomy table of the ancients.
A commode, or an  ordinary table, a stump bed firmly fixed and prop-
erly prepared, are  less repulsive and will always suffice for those sur-
geons,  who do not  wish to appear  over nice by exacting special
contrivances.   What is  necessary is, that  the  patient, placed  on his
back, should have his head and chest  in a flexed position, and slightly
raised, that the pelvis should not be allowed to sink into the mattress,
that the perineum may come  beyond the  edge of the bed, and that
the assistants may  have room to place themselves around.  We hear
no more to-day of  seating him doubled up upon the knees of one or
two strong men, as at the time of Celsus, nor  after he is laid on his
back, of lashing him down by means of cords  passed under his arm-
pits, and then around the upper part of his thighs,  and upon  his feet
and hands, as was  prescribed  by the Mnemonists.   The  straps also
of the figure of 8 employed by Le Dran,'are no longer found neces-
sary.   When it is recollected that  no  kind of cords has ever been
prescribed for the  operation of hernia or  aneurism,  we  cannot too
clearly  perceive what can make it so very urgent  for lithotomy, ex-
  vol. in.                     75 
594          NEW ELEMENTS OF  OPERATIVE SURGERY.
 cept it be in children and in individuals devoid of reason.  Hitherto
 I have dispensed with their «se without having any cause to regret
 it, vet the operation, nevertheless, in one of the patients confided to
 mv care, the one from whom I extracted an enormous  stone in the
 month of October.  1830, at La Pitie. was  one of the  most severe
 character.   Upon the supposition,  however, that we decide  upon
 having recourse to cords, either as  a matter of prudence or necessi-
 tv, we are to hive a bandage of woollen, or should that be wanting,
 one of pliant linen, three fingers' breadth in  width, and two  or three
 vards long.   With this bandage, which is to be doubled  in the direc-
 tion of its  noose, we make a  running knot, which  is to be applied
 and fastened on the wrist of the patient, and which is then immedi-
 atelv  to include his heel,  while leaving the thumb on the fibular side,
 the "fingers below and the radial border of the hand in  front.  The
 two heads of the bands are then seized by the surgeon, who separates
 them  and passes them, one inwards  and the other outwards,  then
 crosses them upon the instep, and carries them to the plantar surface
of the foot,  brings them  back above,  and then  behind, and finally in
front, at which place he fastens them  by a  bow-knot, taking care to
leave its  free extremity to the  outside.   The foot  and  the hand on
each side  thus  tied, aie  confided to two assistants, who are placed
one on  the left and the other to the right,  outside  of the limb,
while their  backs are slightly turned towards  the  head of the bed,
which assistants would  have  the same duties to perform if we did
not make use of bands.
   While  with the hand which looks towards the pelvis, each of them
grasps the corresponding knee, as if for the purpose of separating it
from the  axis of the  body, he makes use of the other  hand, while
turning  it in pronation, to embrace the foot on its inner border and
dorsum ;  if he had placed his hand underneath, the patient might find
in this a point d'appui, which he might use in trying to raise  up his
pelvis, which ought to be particularly avoided.  This disposition to
raise  up  the pelvis,  which  is observed especially  in infants,  and
combined with a movement to the right and to the left, or of rota-
tion, is so difficult to control, that it requires the intervention  of a
third assistant, who should be  stout and strong, and place himself on
 the left.  In applying the palm of the hands on each corresponding
iliac crest, with the thumb extended upon the front part of the antero-
 superior spinous process  down to the  fold of the groin, he regulates
 these movements by the  simple effect  of pressure, and is  not in  gen-
 eral but very little  fatigued.  A fourth aid, seated upon the table
or bed, watches the movements of  the head, and keeps the eyes of
the patient  covered  with a compress.  A  fifth is  placed upon the
 right and opposite to the side, to keep in the sound and raise up the
scrotum.  Finally, to the sixth is assigned the duty of handing to the
surgeon all the different objects which he may have occasion°for du-
ring the course of the operation.
   IV. Introduction and adjustment of the sound.__Before  proceed-
ing to the division of the tissues, the operator introduces the sound
 into the bladder, where he does not fix it  until after havin^ a^ain
 recognized the  presence of the calculus, and corroborated thelfact by
 some of his  assistants.  It has been for a long time adopted as a rule 
LITHOTOMY.                        595
 to incline the plate of the sound towards the right groin, in order
 that its convexity may press the perineum more or less to the left
 of the median line, and  obliquely backwards  towards  the  ischium,
 but it is doubtful if this rule has any great value or any thing else to
 support it than long usage, or at least, when our intention is to open
 the  prostate with the gorget  or concealed  lithotome.   This inclina-
 tion in  fact does not change the direction of the walls of the urethra
 in its relations with the  axis of the canal.   Of what  importance is
 it after all, whether we open the urethra upon the  side or upon the
 median line, so long as we have nothing to do but with its membra-
 nous portion, or the making  a  passage  for the  other  instruments ?
 The only argument that may be adduced in  favor of a practice of
 this kind, is the greater facility; perhaps, by which we may thereby
 avoid the  bulb, by crowding back  to the left the  urethral  portion
 which  this dilatation conceals, and by thereby removing this imped-
 iment to the  subsequent steps of the  operation.   It  is therefore a
 matter almost of indifference, whether we place the sound  to the
 left as is generally done, or  on  the  median  line as Scarpa and A.
 Cooper prefer to do, even though  we are performing the lateralized
 operation.  Almost all  surgeons  of the present time,  in place of
 holding the sound themselves with  the  left hand, with  the view of
 following its movements better or more advantageously varying its
 position, according  to circumstances, as  is the  practice of various
 operators after the advice of Pouteau, hand it, as soon  as  its loca-
 tion is clearly decided upon, to  the  care of an  intelligent assistant,
 who ought to be well acquainted with its character and uses.
   B. Operation.—I. Incision.—The surgeon with a bistoury which
 he has selected and  holds in his  right hand, stands up, or if his sta-
 ture in  respect to the position of the patient appears to require it,
 rests his right knee on the floor without the necessity of a stool or
 bench to support him, and then divides first the integuments, which he
 stretches with the thumb and fingers of  his other hand, without pay-
 ing any attention to the scrotum, which the assistant charged with
 the care of the  sound, gently raises  up with his right  hand.   This
 incision should commence on  the left side of the raphe, at  about an
 inch in  front of the anus, and  should be carried obliquely backwards,
 terminating nearly at the middle of the space which separates the tu-
 berosity of the ischium from the opening of the rectum, and should
 be from three to four inches long.  If it were nearer the scrofum it
 would expose to the danger  of infiltration, and could  have no ob-
ject.  Its prolongation towards the sacro-sciatic ligament is useless.
If it were  too short it would interfere with the extraction of the
stone, and would not give sufficient facility to the  flow of the urine.
If it were nearer the median line, it  would frequently fall upon the
rectum ; and  if, after the manner of Roux, it should be made very
near the ischio-pubic branch, it could  not preserve its parallelism with
the incision of the deep-seated parts.  The bistoury being now re-
applied  into  the upper angle of the wound,  is  then to divide the
sub-cutaneous layer, the posterior border of the  transverse muscle,
and in succession all the other layers which  separate the skin from
the urethra, with this precaution, that it should rest much more upon
*he median portion, than upon the two extremities of the solution of 
596          NEW ELEMENTS OF OPERATIVE SURGERY.
continuity.   Rather than continue this  manipulation until  we come
down upon the directing instrument  thus laid bare, it is better at this
time to seek through the tissues which  have not yet  been divided,
the groove of the sound bv  means of the  left  forefinger,  and to
place the right ed^e of this groove between the nail and the pulp of
the finger, the radial border of which finger should be turned  down-
wards.  The surgeon, without stopping, glides the  point of the  bis-
toury, which is held like a  pen, upon the nail  which remains fixed,
then pierces the  lower wall of the  urethra  a little in front of the
apex of the prostate, and now arrives into the groove of the sound.
The guiding finger is then immediately  brought round upon the back
of the bistoury,  the  point of which latter the operator  pushes  to-
wards the gland, to the extent of ■ three or four lines, while with
the other  hand  he  raises  up its handle and continues to press the
point against the groove in which it is lodged.  If it  should escape
from  it, we  shpuld  be exposed to the risk of perforating the rec-
tum.   Uretro-cutaneous fistulas have  been  produced in this man-
ner ;  one  instance of which  I  have seen, while another has been
mentioned by Dupuytren and  M. Begin.  The  forefinger resumes
its fixed position on the edge of the sound, after which the right
hand  withdraws the knife, at the same time that it presses  its heel
by a vibratory  movement, in  order in this manner to enlarge the
opening through the tissues that are in  the nearest proximity to the
urethra.
  II.  The moment of introducing the lithotome, whatever may be the
description selected, is now arrived.  If it should be that of F. Come,
the operator seizes it by the handle, and without touching its mova
ble piece, glides  its beak upon the  nail in the urethral opening, in
such manner as to fall perpendicularly upon the groove of the direc-
tor, and makes with it a few movements backwards and forwards, in
order to satisfy himself that it has  been  properly introduced.   When
he has positively recognized the  metallic contact of the two instru-
ments, he raises  himself up if he has been resting on his knees ;  dis-
engages his  forefinger from  the  wound; seizes  hold  of the sound
and  depresses its plate ; and gives it a  vibratory  movement with his
left hand, while with his  right he glides  the point  of  the lithotome
along its groove into the bladder, when the escape of a small quan-
tity of urine soon shows him that it has entered into the organ.
   Ill:  The employment of the gorget  exacts the same precautions.
Prudence does not permit us to proceed in a less methodical manner
when we  give  the  preference to the tongue or probe-pointed bis-
toury, or to  the small knives with fixed handles,  whether straight or
convex.  If the  vesical extremity of the sound had not been pushed
back towards the symphysis  pubis to give room to these  instru-
ments, they would not, it is true,  therefore divide  the prostate,  but
their point or their cutting edge would almost unavoidably come in
contact with the trigonus vesicalis, or frequently cut entirely through
it.  In following, on the contrary, its groove, at  the time of making
this elevation, they place the point of the instrument in relation with
the vertical axis of the bladder, and penetrate without danger to such
depths as  may be desired, and in such manner that we may, while
withdra wing them, give to the incision  all the extent required.' 
LITHOTOMY.
597
  IV.  The object of the sound having been effected, it is to be with-
drawn.  The hand which  holds the handle of the  lithotome places
some of its fingers below its movable piece and opens it; the other
hand is placed upon  its back on a  line with the articulation of the
sheath with its blade, the thumb being upon the right side, the fore-
finger  semiflexed upon the left side, with  its  radial border  turned
towards  the pubis.   Its  cutting edge being inclined in the  direction
of the exterior wound, or in any other manner, should it be  preferred,
there is nothing more for the two hands to do  than to withdraw the
instrument by their combined efforts.  The office of the left hand is to
see that its sheath, while the instrument is being withdrawn, does not
become separated from the point on the pubic  arcade, against which
its  concave  or  dorsal border  had  been first  made  to rest.   The
right hand, which is charged with the duty of withdrawing it to the
outside, has  to  guard against  two  difficulties.   If the wrist were
raised  up too much, it would give  greater depth to the incision at
the  base  than at the apex  of  the prostate; too great a depression
would produce a contrary effect,  and moreover would  expose to
the danger  of wounding the  rectum.  If  it was not made to rest
against the  osseous  arcade, it  would have  no fixed  point, and  the
dimensions  of the wound would vary according as  its blade should
be  directed with a greater or less degree of force downwards;
this is one of the inconveniences of the gorget and of bistouries.
  V. Moreover, whatever may be the instrument by which the de-
bridement is effected, we would find no other advantage in avoiding,
as Moreau recommended, the layers situated immediately underneath
the prostate, than that of respecting the rectum with greater cer-
tainty, for it is not  at  this  point that we find  the transverse artery
of the  perineum; but a dangerous difficulty would result from it for
the passage of the  urine.  As  on the other  hand the intestine is suf-
ficiently protected by the obliquity of the incision, it behooves us not
to follow this practice.  The more the axis  of the wound approaches
to a perpendicular  position, that is to say,  to  the axis of the  body,
the more chances there are against infiltrations and abscesses.   In
conclusion, as the deep incision has for its object the enlargement of
the entrance of the  urethra to as great an extent as  possible, without
going  beyond the contour of the prostate,  it ought to be made upon
the largest diameter  of  this  gland, not only from the centre to  the
circumference, but also from before backwards, and in such manner
that the circle of its base alone shall be respected.  Here lies  the
problem to be solved in the lateralized operation.  Now the slightest
reflection  shows that to effect this object, the division of the urethra
in its membranous portion is attended with  no  advantage ;  and that
all that is  necessary is to  open this passage posteriorly, quite near the
apex of the prostate, and consequently near the  horizontal aponeurosis
of the  perineum.  We see, for the  same  reason, that it  is wholly
useless to prolong  the incision of the other tissues forward in the
direction of the  pubes, since its only object is  to form a sufficiently
large passage for the calculus,  and that in respect to the consequen-
ces of the operation  or  the  effusion of urine, the  posterior direc-
tion especially is the one in which the incision should  be enlarged.
  VI.   The  lithotome being  now  no  longer required, is handed 
598
NEW ELEMENTS  OF OPERATIVE SURGERY.
 back to the assistant, and in its place is  immediately substituted the
 left forefinger, which in order to enter into the bladder must be intro-
 duced from below upwards, and from behind forwards, and by which
 we ascertain: 1st, the interior condition  of the organ ; 2d, the  posi-
 tion,  and sometimes the size, form,  and even  the number of stones
 contained in it;  and 3d, the dimensions of the wound.  Precautions
 should be taken to prevent it, while penetrating, from lacerating either
 the intestine or prostate, by blundering between the  rectum  and this
 gland.  Before withdrawing it. we introduce upon it the probe-point-
 ed bistoury, to enlarge the incision either of the prostate or perineum,
 or in this or that direction, should it be found too narrow.  The fin-
 ger may be then used as a director  for the bouton, or for the gorget,
 or even for the tenacula.   It is better, in order to carry out this indica-
 tion, to place the finger in the lower angle of the wound, with the nail
 turned backwards, than to place it above, and for this  reason,  because
 the instruments which it is intended to guide have more tendency to
 escape between the tissues  posteriorly than in  front.  The bouton
 being longer, and of less size than the gorget, passes with greater fa-
 cility around the entire vesical cavity, and comes down better upon the
 stone, whatever may be its position, but it is afterwards attended with
 a little more inconvenience as a conductor of the tenacula.  We may
 moreover dispense with either in a great number of cases, and in-
 troduce the tenacula immediately upon the finger.  As soon as  they
 have  performed their exploring duties, they are to take the place of
 the finger in such manner as to  be enabled to depress by this means
 the posterior angle of the wound.
   VII. The operator with his right hand now  become free, presents
 the tenacula above, one of the branches to the right, and the other to
 the left, and gliding them into the gorget, or embracing the crest of
 the bouton at their edge which is opened, he pushes them in the same
 manner as he had done with the finger, and in this manner penetrates
 into the bladder, at the same time that he disengages the conducting
 instrument from them.   Before thinking of grasping the calculus, he
 again endeavors to touch it by various movements of the instrument.
 This being done, we have now finally arrived to the last stage of the
 operation, which is frequently the longest, sometimes the most diffi-
 cult, but usually the  most simple and rapid.   The surgeon then opens
 the tenacula by making traction upon each of the rings, by means of
 the thumb and forefinger of the  corresponding hand. When their
 branches are sufficiently separated apart, he makes a sudden move-
 ment with the instrument from right to left, to  the extent  of  a quar-
ter of a circle* upon  its  axis, in such manner that one of its scoops
 is immediately placed below and the other above, and that the branch
 below grazes, so to speak, the vesical wall, and may glide underneath
 the calculus.   If this first movement does not  succeed, it is to be re-
 peated, either in the  same direction, or from left to right, or by eleva-
 ting or depressing the wrist still more.
   VIII. The stone being once seized, may widen the handles of the
 tenacula to a greater extent than had  been supposed, which arises
 from its being too  near the joint of the instrument, from its not  hav-
 ing been embraced by  its  smallest diameter, or from our having been
 deceived in respect to its volume.  It is an inconvenience which  may 
LITHOTOMY.
599
be remedied in the  two first cases, by pushing back the calculus be-
fore the tenacula by means of a sound,  without entirely relaxing our
hold upon it, or by making such movement upon it, that it  may
present itself at its  smallest diameter.  In the tlffrd case, there is no
other resource than to enlarge the prostatic opening, should  it not ap-
pear to be of sufficient dimensions.  In conclusion, it is  better to let it
fall out and to seize it again, than to persist in attempting to change its
position between the branches which retain it; it being well understood
that if it is not very large, all  these precautions  are in general un-
necessary.  If the stone should be flattish, and much  longer in one
direction than in another,  it might, though seized by its  smallest diam-
eter, be necessary to relax our hold upon  it, asid  then to  grasp  it
again, should it have become placed transversely in the wound.   The
same would be the  case with any elongated  stone whatever, or with
the cylindrical or cucumber shaped  calculus, &c.  These peculiari-
ties are indicated by the resistance which is suddenly perceived at the
moment when the tenacula are upon  the point of being entirely with-
drawn from the bladder. Even without bepg opened, they may, from
their leaving between their branches a certain space, which  prevents
them from compressing the organ, have got  the calculus lodged and
confined between them, should it be  small and flat, and this without
the  operator being aware of it.   We may, however, presume this
to  be  the case, when,  after having  touched it,  and endeavored to
grasp  it, we can feel it no more.  In a case of this kind, we with-
draw the tenacula, in order to be certain  of the  fact.   Moreover,
it not unfrequently happens that small calculi make  their escape with
the flow of urine, or become arrested in the track of the wound, and
thus for a moment give  rise to  doubts as to their existence.  I  will
now suppose that  the  stone has  been finally seized.   The  tenacula
being now replaced horizontally, the  surgeon seizes their rings with
his right hand, and fixes them as near as possible to the branches, by
means of his left hand, turned  in supination, with  the thumb above
and the fingers below.   He then commences the tractions, after hav-
ing thoroughly convinced  himself that the stone is free, and the only
thing embraced.   For that purpose he  confines himself to making
pressure on the tenacula from above  downwards, with the thumb of
one hand, in order that the instrument  may  rest chiefly against the
posterior angle of the wound, while the other hand makes such efforts
as are  suitable.   These  movements are made to the  right  and left,
and above and  downwards, rather than in  a direct line.   We  take
care, however, to make  them follow the axis of the pelvis in  the same
way as for extracting the head  of the infant by means of the forceps.
  IX.  Should  the straight forceps constantly pass above the stone,
without being enabled to embrace it  with its scoops,  or, in  fine,
should the stone have escaped from it in consequence of being turned
aside, or too much depressed in its position, or from being situated in
too deep  a cavity, the curved tenacula would then be indicated
Being  introduced like the others, they should have their concavity
turned in  the direction  in which  the calculus is situated, in order to
seize it, and in order to extract it, be brought out in an opposite direc-
tion.   The forceps  tenacula, contrived by F. Come, can scarcely be
necessary except for large sized stones completely embraced by the 
600          NEW ELEMENTS OF OPERATIVE SURGERY.
bladder, being of that  class of calculi  which Ammonius (Dujardin,
Hist, de la Chir., p.  340,)  recommended  should  be first broken
up, in order afterwards to extract  their fragments with  facility.
The branches of thfce  forceps tenacula are to be placed in succession
by making them glide gently between the walls of the organ and the
foreign  body; we  then  lock them together in the  same manner, pre-
cisely as when we are manipulating  with  the obstetrical forceps.
   X." After the calculus has been extracted, we are to examine its ap-
pearance.   If it is  rounded off and of an elliptical, oval, or elongated
form, but destitute of angles or facets, we are justified in supposing
that there are no others in the bladder.  Calculi  which are covered
with asperities would lead to the same conclusion, while those which
present facets indicate  the contrary.  This examination,  however,
which can  give nothing but  probabilities,  does  not  allow us to  dis-
pense with further researches.  The  finger or the bouton, therefore,
is to be reintroduced into the cavity  of the organ, in order to ascer-
tain positively what we have to depend upon.  Some bladders more-
over contain a  considerable number of calculi.   The bladder  in a
person who had been operated upon three times was found still to
contain  300 calculi when the  autopsy was made by M. Ribes.   The
journals have spoken of a patient in whom M. Roux extracted near
100; while Murat, (Arch. Gen. de MM., t. VIII.,  p.  131,) in another
patient,  counted 678.  M. Souberbielle has shown me sixty-six that
he extracted from a bladder after the  operation for lithotomy. I
found 160 of them in a patient, in 1836.  It  is important that none
of these calculi should  remain  in the bladder, or even in the track
of the wound.   As  they  are ordinarily small, many of them may
become easily lost  in the midst of the tissues.
  XI. The volume  of the calculus may also become a source of em-
barrassment.  If they exceed two inches in  their smallest diameter,
it  is frequently impossible to extract  them  even by the recto-vesical
operation.   It was in a case of this kind that Dupuytren laid open
the anterior wall of the  intestine, after having performed the bilateral
taille.  Various instruments have been proposed, under such circum-
stances, to break and reduce them into fragments.  That of F. Come
has two pyramidal teeth on  the interior of the branches, which are
filed down flat.   The stone-breaking tenacula of B. Bell are also pro-
vided with teeth, and a quick screw going through their handles.  The
forceps  contrived  by M. Sirhenry to break  up the calculi by pene-
trating through the urethra, the virgule forceps  of M. Heurteloup,
the friction forceps of M. Rigaud, the jointed noose of M. Jacobson,
and almost all  the  lithotritic forceps might also effect  the same  pur-
pose.   These last mentioned instruments would also have the advan-
tage of  enabling us to perforate  the calculus, should their ordinary
construction not be found sufficient to break it, and they oun-ht there-
fore, in  my opinion, to  be preferred; but  the stones which render
such manipulations indispensable  are so voluminous and difficult to
embrace, that we  generally prefer having recourse  immediately to
the hypogastric operation, and thus to extract them above the pubes.
M. Mattuizzi, (Bull,  de Fir., t. X., p. 277,) in a  patient who after-
wards recovered, was enabled to extract a stone of eighteen ounces
through the perineum.   A debridement of two  lines,  performed on 
LITHOTOMY.
601
tht fifth day, enabled M. Alaman (Bull, de Therap., t. XIII., p. 169,)
to extract a calculus of the weight of six ounces, and which, after hav-
ing resisted his efforts, had become spontaneously lodged in the wound.
   XII.  No person at the present day is alarmed to%o great a degree
at finding  the calculus, when it is very friable, crushed between the
branches  of the forceps,  as to think of employing the quadruple for-
ceps of Bromfield, the graduated tenacula of Lecat, the filet-en crin
of Has, the forceps  of Home with a  circular  development, or the
triple tenacula with  eyed branches, as made by the cutler Cluby of
Sheffield.  Should this accident happen, it is found to be more con-
venient to seek in succession for  all the fragments by means of the
same forceps,  and to extract  their particles by means  of  emol-
lient injections.   I have,  however, operated successfully on a patient
who suffered a great deal from this accident.  The stone, which was
broken up into an infinity of angular fragments, and which, moreover,
had the appearance of a  mural calculus, had  become glued in frag-
ments to the walls of the bladder, like  patches of concrete mortar
upon wet rumpled linen,  so that it became necessary, so to speak, to
scrape its interior with the scoop and finger in order to extract them.
   XIII. The fixed condition of the calculus  has  given  much  more
embarrassment to operators.  Before wasting  our time in useless
efforts we endeavor to  recognize with  the forefinger what  is the
nature  of the difficulties  which present themselves.   If the foreign
body appears to adhere only upon one of its sides, it is probable that
fungosities or vegetations have  become introduced  or grown  up
between its bosselures.   In this case the process of Lapeyronie, as
employed  by Marechal, Le  Dran and  Boyer, and which consists in
making methodical traction  on the stone as soon as it is grasped, in
order to tear it out, is the only one which is applicable  in all  those
instances in which we have not been enabled to detach it by jogging
it  with  the finger, scoop  or bouton.  If it should be encysted and
adherent at the same time, the breaking down the cyst with a grooved
sound, as  recommended  by  Littre, would amount almost to nothing.
We should scarcely succeed any better  by mashing  it with the
branches  of  the tenacula, as is also recommended  by the  same
author; the tearing of it out then  also is the only remedy.   When it
is  merely  arrested by a bridle or retained in an open cyst, but  with-
out any adhesion, the cutting instrument will not always be  unat-
tended  with  advantage.    Garengeot,  Leblanc  and  Desault  had
recourse to it with  success.  A  probe-pointed  bistoury should  be
cautiously directed upon the  free border of the cyst, and then inserted
flatwise between  its  inner surface and thfe calculus, in such manner
that in bringing its cutting edge outwards it may incise the accidental
pouch to a convenient extent from its summit to its base, in the same
way nearly as would be  done in a hernial debridement.   Nothing
would prevent our repeating  this incision on other points of the bridle,
if  the first should prove  insufficient, or should it  have appeared to
have been attended with  too much danger to carry it to the distance
desired.   The tonsil kyotome or bridle cutter  used by Desault,
is certainly not as good as the bistoury of Pott, and ought not  to be
adopted.  The ordinary straight bistoury used by Garengeot has two
disadvantages : 1st, its point is constantly in danger of wounding the
   vol. in.                     76 
602
NEW ELEMENTS OF OPERATIVE  SURGERY.
 walls of the bladder; 2d, it neither glides nor is introduced with as
 much facility as the probe-pointed bistoury between the cyst and the
 surface of the stone.   The surgeon  however  ought  not to  forget
 that the bridles formed by a mere partial contraction of the bladder,
 and the abnormal  sacs developed external to this organ in place of
 projecting into its  interior, would not allow  us  to make incisions of
 this kind, except with extreme caution, since  from their acting in such
 cases on  the  walls of the bladder itself, they  would  rarely fail to
 wound  the peritoneum.   There would however be an exception to
 be made in favor of  calculi fixed in  the urethra by one of their ex-
 tremities.   As the  orifice of this canal traverses very  obliquely the
 tissues of the bas fond of the bladder, it might, in fact, be incised
 separately to the extent of several lines without any danger. Finally,
 if the  calculus was  in the form of a gourd, for example, and was
 arrested by one of its portions, either in the  urethra or an accessory
 pouch  of  the  bladder, we should have to  resort  again to  various
 movements  and tractions, and  not  attempt incisions except as a
 desperate remedy.
  XIV. The foreign bodies, which are sometimes  designedly  intro-
 duced  into the  urethra, such as sounds, bougies,  &c, sometimes
 escape either as fragments or entire into the  bladder.  Their extrac-
 tion  should then be effected as soon as possible.  M. Ferrier,  (Rep.
 d'Anat. et de Phys., t. IV.,) by having fixed the lower end of the piece
 of a sound against  the arc of the pubes by making compression upon
 the perineum, was  enabled to extract by means of a turrel; and M.
 Tyrell reached one in the bladder and ultimately extracted it by means
 of the forceps  of Weiss, (Encycl. des Sc. Med., 1836, p. 241.)   In a
 similar case M. Haime (Prec Med. d'Indre et Loire, 1820, 1st trim.)
 also succeeded without recurring to a bloody operation.   Duse and
 M. Segalas have extracted them by means of the litholabe with two
 branches.  But it quite frequently happens that we are obliged, under
 such circumstances, to have recourse to the operation.  A patient of
 M.  Roux, (Dubourg, Journ. Hebdom., t. IV., p. 11 ;  Andral, Thise,
 No. 293, Paris, 1837,) who was operated upon in this  manner for a
 sound which had escaped* into the bladder the  day before, died on
 the seventh  day.  Those of MM. Viguerie  (Journ. Hebdom.,  1834,
 t. I., p. 183) and  Moulinie, (Bull. Med. de Bord., 1833, p. 41,) on the
 contrary,  were perfectly restored.  Dupuytren, it is stated, has per-
 formed the operation five times, and Beclard  (Bull, de Therap., t I.,
 1832) once for this description of accidents.   Certain is it that a great
 number of practitioners, with Lesage, M. Duval, (Bull, de la Fac de
 3Iid.,t. VI., p. 420,) <fec., have made mention of sounds  that have be-
 come broken off in the urethra or escaped into the bladder   Sup-
 posing then that the foreign body could not be seized in the urethra
 ^y ?eu,nS^f tu6 Processers mentioned in the paragraph on calculi, nor
 in the bladder by means of the forceps already  described, it would then
 be necessary  to have recourse  to cystotomy.  In  such cases the
 perineal operation, which is  the most simple,  would  evidently be
found sufficient, since it is unnecessary to make  a large incision into
the  parts   The finger,  a blunt hook, or  a polypus,  urethral or
hthotnty forceps would  then  be found  sufficient  to  remove the
sound or the broken portion of it in the bladder. 
LITHOTOMY.
603
  XV. The operation in two stages.—The difficulties attending the
grasping or extracting of the  stone, and the danger of occasioning
too much suffering to the patient, by tedious explorations, have sug-
gested the idea of performing lithotomy in two stages,  that  is to
say, to confine ourselves at first to the opening  of the bladder, and
to defer to another period the extraction of the calculus.   The Arabs
had already entertained the same idea, for Albucasis says, that  if a
hemorrhage should supervene,  the surgeon ought to dress the wound
with vitriol, and then wait.  Franco, who revived this practice, wait-
ed from three to five days. Maret de Dijon, however, is the first person
who endeavored to generalize it.  This principle has also been support-
ed by Kamper and by T. Haaf, which last did not undertake to search
for the stone until at the expiration of 8 days, and more recently
by Guerin, of Bordeaux.   No doubt that in adopting it, it  has  been
hoped that the foreign body would of itself have escaped through the
wound, or come out  upon the dressing, or  at least approximate the
passage  which had been made for it, and be no longer attended with
so  much difficulty in reaching it.  But in  opposition to  these ad-
vantages, we  have the restlessness of the patient, the irritation which
the presence  of the  calculus constantly causes, and  the acute  pains
which are necessarily produced by the  tenacula in passing through
a wound;  in a word, we have two operations instead of one.  Modern
practitioners,  therefore, have rejected this modification  of the opera-
tion,  and do  not come to the  alternative of leaving  the stone in the
bladder, when they have made the division of the soft parts, except
it be impossible to act otherwise.  As to a  transverse  incision, as
Paul  and Avicenna (Theses de Hatter, t. II., Fr. trans.,) recommend,
or to the right rather  than to the left, as is advised by Tarin, (Ibid.,)
in the lateralized operation, these are precepts which at  the present
day are lost sight of in the methods established.
   XVI.  Injections.—From the apprehension that particles  of gravel
may be  left behind in the bladder, most operators  are  in  the  habit
of  washing it out freely, by means of injections of tepid  water or
emollient decoctions.   If these injections are methodically made, they
can never do any injury.  As they have the advantage of cleansing
out the clots of blood and the  flocculi of mucus,  as well as the  frag-
ments of calculi, which frequently escape the most minute exploration,
we do not see how  they  could  be  dispensed  with.   In order to
make  use of them we should  be provided with  a large, or injection
syringe,  which would contain a litre  of liquid.   W thout this  pre-
caution the amount of contained fluid  would not possess sufficient
force to  drive out the matters that we wish  to expel.   In  order not
to wound the organ we may  make use of a syphon, which termi-
nates in the manner of the spout of a watering-pot, and is made either
of tin  or gum-elastic.  With a little  address, however, and in  trac-
table  subjects, the  simple syphon does not expose to any risk.   After
the first  injection  we usually  make use of a second, and  even of a
third,  in order to  be sure of detaching all  the foreign  substances.
The patient is then to be immediately  cleansed with a sponge and
tepid water ;  after which we  unloose the cords, or other  confining
means which  the operation had rendered necessary.  We then  place
him on  his back  in bed, with the head and chest slightly elevated, 
604
NEW ELEMENTS OF OPERATIVE  SURGERY.
 and with his lower limbs brought together and semiflexed, and sup-
 ported  by a sheet, rolled in  the form  of a cylinder, or by a  trans-
 verse bandage passed under his hams.  It is unnecessary to  tie his
 legs or  thighs,  as  was still  done in the  last  century, in order to
 prevent them from being separated  apart.  Nor is  it necessary to
 keep him permanentlv even in a dorsal position.  It is necessary that
 the patient should incline to one side  or the other, and that he should
 not confine himself to his first position only to the degree that it does
 not become too fatiguing for  him.
   XVII. Canula in the wound.—For a long time since,  the  sound
 has no longer been left in the  urethra to re-establish the course  of the
 urine.   The same nearly may be said of the canula, which a consid-
 erable number of operators considered it proper to leave in the wound
 a certain number of days after the operation, and which was intend-
 ed to prevent infiltrations by  conducting all the  effused liquids out-
 wardly.  This  canula, which was disapproved  of by  Schmucker,
 (Bibliot. Chir. du  Nord, t. I., p. 39,) but which some  practitioners,
 and M. J. Cloquet in particular, still make use of, irritates the wound
 and neck of the bladder, and  even the interior of this organ.   It be-
 comes a foreign  body, which interferes with the salutary efforts  of
 nature, fatigues the patient  to a  greater or less degree, and of  itself
 alone may give rise to serious accidents.  I have seen it used  in an
 old man 84 years of age, who was soon seized with adynamic symp-
 toms, and died at the expiration of 11  days.  The whole extent of
 wound was covered with a grayish colored concretion;  pus had be-
 come infiltrated into the neighborhood, and traces of purulent inflam-
 mation had extended even into the interior of the pelvis.  Should it
 ever be  deemed necessary to  present  any obstacle to  the approxima-
tion of the lips of the wound, it would be better to place in it a meche
of ravelled linen, or a simple tent of lint, than a canula.

            § VII.—Accidents  of Perineal Lithotomy.

  It is perceived that the perineal operation must be one of a painful
 and serious character.  Instances however are cited, in which the pa-
tients have performed it upon themselves.  The blacksmith mentioned
by Tulpius, (Bonet, Corps de  Med., t. III. and t. IV.,  p. 42,) and the
 physician Clevel (Bull, de Fer., t. III., p. 59) must have been exam-
 ples of this kind.   The truth  may not resemble the truth!   Perhaps
 also in these cases the calculi  had come out of the  bladder and pro-
 jected at the perineum.
  A.  The first accident which we have to fear in the lateralized ope-
ration, and in perineal lithotomy in general, is hemorrhage, which
 may show itself in three different ways: at the time itself of'making
the incision  into the  tissues,  in the course of the  first  twenty-four
hours which succeed to the operation, or only after the expiration of
 a certain number of days.   In the first case, it may depend, as.  I im-
agine, upon a lesion of the superficial artery, of the transverse artery
of the perineum, of the hemorrhoidal, or of the trunk of the pudic, of
the prostatic venous plexus, or as I presume of some anomalous artery
like that which passed through the prostate in the patient mentioned
by Shaw, (Bull, de Fer., t. VII., p. 269.)   The hemorrhage comes 
LITHOTOMY.
605
from the superficial branches, if the blood escapes from the upper angle
of the wound, or from the sub-cutaneous layer; and from the trans-
verse artery, on the contrary, when the finger introduced at a certain
depth, arrests it  by making pressure on the external lip of the wound
opposite the bulb and the membranous portion of  the urethra.   The
hemorrhoidal  will be the source of it, if the blood escapes by the
lower angle of the wound.  The hemorrhage will also be found pos-
teriorly and to  the outside, but at  a great  depth, in those cases  in
which the pudic artery itself shall have been wounded.  The hemor-
rhage which arises from a division of the veins, or  which is caused
by the section of an  artery situated around the prostate, will, from
having its source at a greater depth than any other,  be distinguished
from  the preceding by the color of the blood in the first case, and  in
f!fie second case by the fact that the pressure made by the finger on
all the points of the perineal wound will be found insufficient to sus-
pend  the flow of blood even momentarily.  So long as the flow of
blood does not  take  place per saltum, and  that  it  does not flow  in
such  considerable quantity as to occasion much  debility in the pa-
tient, we need not make any effort to arrest  it.  In  many cases it is
a  salutary bleeding, which may prevent a number  of serious  acci-
dents.  If, on the contrary, it threatens to be abundant, and to con-
tinue, and if the patient is enfeebled or at an advanced age, it is ad-
visable to check it as soon as  possible.
   The most efficacious, and at the same  time most  simple means, is
the ligature, when it shall be found practicable.   When the divided
artery can be seen in  the interior of the wound, it is to be seized
with a dissecting forceps, or if it is not sufficiently isolated, by means
of a tenaculum,  after which we immediately pass the ligature around
it.  If the artery in question should be the pudic, and its extremity
could  not be seized without too much difficulty, we should,  I conceive,
imitate Physick, who wounded it in his first operation for lithotomy,
and pass between it  and  the ischio-pubic ramus a double thread,
by means of J. L.  Petit's curved needle with a handle.  This needle
would be introduced through the interior of the wound, and  pass on the
outer  side of the artery behind its division, in order  to re-enter into the
solution of continuity, where the thread would be disengaged from its
point  in order to  enable us to withdraw the needle, and the liga-
ture then knotted intermediately on the tissues.   I do not  think
in such cases, that we should ever think of passing a ligature through
the obturator foramen in order to encircle the ischio-pubic ramus  at
the same time with the  artery, as is recommended  by M. Caignon,
(Arch. Gen. de Med., t. IX., p. 137,) nor that we should apply a liga-
ture upon the vessel at the point where it passes through the sciatic
ligaments, as is advised  by M. Travers.  This wound, moreover,  is
so rare, and one  which it would be so difficult to make, unless we
deviate  from all the rules  of sound  surgery,  that  the means  pro-
posed to meet its dangers cannot  possess any great degree of value.
It is probable,  moreover, that a deception has in  more than one in-
stance arisen  in this matter, from  the  hemorrhage being caused
by  abnormal  branches, or  by  secondary  ramifications that are
somewhat more  largely developed  than  usual.   Upon the supposi-
tion that the artery could be  seized and isolated with sufficient ease, 
606
NEW ELEMENTS OF OPERATIVE  SURGERY.
but that it was too high up to surround it with a ligature without being
attended with considerable difficulty, we should not hesitate to make
torsion upon it by means of the forceps with which we had seized it.
Finally, if neither torsion nor the ligature are practicable, and it should
become necessary at every hazard to put a stop to the hemorrhage, there
are various other means that may be made trial of.   The solid sound,
arranged in such manner as  to fill up and press against the whole extent
of the wound, as was still  practised not more than half a century since,
had  the inconvenience of making stronger compression towards the
skin than towards  the prostate, and of frequently  forcing the  fluids
to be effused  into the bladder.   Boyer, like Richerand, (31 em. de la
Soc. Med. d'Emulat., t. IV., p.  275,) appears to have frequently made
use with advantage of a roll of lint  introduced as far as into the blad-
der, and secured by means of a ligature whose two heads were  afte£
wards knotted at the outside, upon another roll, which was inserted as
deep as possible in the direction towards the urethra; but the little ap-
paratus of Dupuytren evidently deserves here the preference over all
the others.   It consists of a canula opened  on its summit and  sides,
around which there is attached  a piece of fine linen in the form of a sac.
It is introduced tc beyond the neck of the bladder, after which we glide
between it and the linen, by means of a dressing forceps, a quantity
of soft lint, until the wound  is completely filled up with it, and in such
manner that it makes a suitable degree of pressure upon its entire cir-
cumference, and with a little more force near the bottom than towards
the skin.   The whole being fastened by means of a T bandage, pre-
sents no impediment to the  flow of urine, and moreover allows of our
increasing or diminishing the pressure in this or that direction, as may
seem advisable.  After the.lapse of two  or three days, the surgeon
gradually withdraws the small  balls of lint, and  soon after removes
the remainder of the dressing.
  If the hemorrhage  does  not make its appearance until after the
expiration of the first few hours, it is rarely sufficiently alarming to ren-
der the interposition of instruments necessary.   It is not because the
contact of the air had  temporarily contracted the vessels, nor from
a  supposed  spasm  of their calibres,  that the  blood, which now
appears, did not show itself at  the time of the operation, but because
the general circulation, which is usually very gentle when  the patient
is on the bed  of sickness, soon undergoes a strong reaction and an
increased augmentation  of  power in its propulsive energies ;  from
whence it follows that the disease then quite frequently becomes its
own appropriate remedy, and  that  these kinds of hemorrhages may
be suspended under the influence of cold  applications or by revulsive
means, which have the tendency to repel the fluids into another direc-
tion.  Thus we  should commence in  such cases by applying cold
water over the hypogastrium,  upon the upper part of the thighs and
to the perineum,  and by injection even into the wound ;  should  there
be fever and hardness of pulse, a small bleeding by the arm would
evidently  be  indicated.  In the contrary  cases, mustard manulu-
via, dry cupping followed by  scarifications between the shoulders,
and cataplasms of mustard to the same regions, should be made trial
of before  proceeding  to  look lor the wounded vessels or to  havin*
recourse to tamponing, unless  the hemorrhage should  be extremely 
LITHOTOMY.
607
copious.  When it does not show itself until after the first days, it is
almost  certain that it does not depend  upon a mere wound of an
artery,  but that it is occasioned by a pure exhalation either from the
wound  or from  the cavity of the bladder.  To admit the contrary,
we should have to suppose that there had been an eschar, which had
become afterwards detached  from the walls of the "essel; or that
there was, as in fact we sometimes find to be the case, a general state
of exhaustion, and a marked dissolution  in the fluids, which has
brought about the fusion of the sanguineous clots, and ail other de-
posits which  had  been interposed  against the  escape of the blood.
We thus perceive  that this must be of the most dangerous kind.  It
does not, however, exact a  different kind of treatment from the other.
A patient who had been  operated upon by the perineal process, by
Dussaussoy, (Soc.  de Sante de Lyon,  1798, p.  145,) was seized an
hour afterwards with a considerable degree of hemorrhage from the
interior of the bladder.  A similar accident took place at the expira-
tion  of several days, in a patient operated Upon by Guerin, (Ibid.,
p. 158.)  On forcibly introducing the finger through the wound, the
bladder was found  to be filled  with  clots.  Injections  and frictions
put a stop to the sanguineous exhalation, and both patients recovered.
   B. Spasm of the bladder.—An accident, which up to the present
time has scarcely been noticed, viz., spasm of the  bladder, existing
to such degree as  to  present difficulties in the extraction of the cal-
culi, appears to have been  frequently met with in children, especially
by M.  Riberi,  (Journ. des Conn. Med.-Chir., 1838, p. 164,)  who
treats of it by  means of tepid water thrown up freely into the wound
with a large syringe.
   C. Wounds of the intestine.—If,  as  I  have seen  in one instance,
the rectum is wounded in the first stage of the operation, or  in any
manner whatever, before the bistoury has reached the neck of the blad-
der, the wound will be found to be underneath the prostate.   As this
accident most  usually happens while we  are withdrawing the litho-
tome, the perforation is then made on a point more elevatedand above
the sphincters, even though we should make use of the plate contrived
by M. Caignon (Arch. Gen. de Mid. t. IX.,) to crowd back the pros-
tate.  The making traction upon the penis while we are incising the
prostate, as recommended by M.  Huguier, (These, Paris,  1834.)
would scarcely be attended with any greater advantage. In quite a
considerable number of cases, we are not at first aware  of the acci-
dent.  It may even happen that there has not been  a complete per-
foration, but that the wall of the rectum,  already greatly attenuated
by the cutting instrument, has been contused  and  mortified  during
the extraction of the  stone, and that the fall  of the eschar is alone
chargeable with the production of the accident.   It  was in this  way
that the accidents appeared to  have taken place in a patient whom I
saw  at the Hospital of St. Louis, in  1822.  In the first case, that is to
say, where we immediately recognize, either by the gases or the pas-
sage of foecal  matters or urine, that the rectum has been wounded,
if the division has been so extensive that we have reason to apprehend
that it may be transformed into a fistula, the most certain means of pre-
venting this termination consists in laying open completely the extrem-
ity of the perineum and intestine as  far as to the anus.   As the con- 
608
NEW ELEMENTS OF OPERATIVE SURGERY.
 traction of the sphincters do not now present any obstacle to the free
 passage of the matters, the wound wiH in general cicatrize with the
 same rapidity as if nothing particular had happened.   In the second
 case, that is  to say, when  some  days have  elapsed, whether  there
 may or may not have been loss of substance, the recto-vesical fistula
 is already  established, and  inasmuch as instances are known in which
 they have  disappeared spontaneously, we  ought  to wait for the ordi-
 nary term  of the cure, and  afterwards treat it in  the same way as we
 would a fistula which might result from any other cause.
   D.  Though urethral fistulas, properly so called, are quite rare at
 the present day, they are still, nevertheless, sometimes noticed; but
 whether they communicate directly to the exterior,  or only reach
 there through the medium of the anus, their treatment being the same
 as that of urinary  fistulas in general, will be considered in another
 article.
   E. Paralysis of the bladder, and retention  of urine, which are
 sometimes  caused  by clots  of blood,  and also the tumefaction of the
 wound and inflammation of the neck of the bladder or prostate, with
 syncopes, convulsions,  incontinence  of urine, and  inflammations of
 every description,  which  may manifest themselves during, or a short
 time after, the operation for lithotomy, do not require other attentions
 than those which are generally known and indicated in the treatment
 of those  affections.  The wound requires more or  less time to close
 up.  The urine usually passes exclusively through it during the space
 of two, three, four, or five days;  after  which the patient from  time
 to time  experiences a desire  to  pass  it.  Finally, he expels some
 drops through the urethra.  It gradually enters into this canal and
 in larger amount;  and finally, from the fifteenth  to the thirtieth day,
 passes through it exclusively.   At this period the perineal wound has
 completely cicatrized.  Nevertheless, it  is not rare to find the urine
take another  mode in its passage outwards.  In certain patients it
 continues .to make  its escape during  two,  three, and even four, five,
 and six months, in  such  manner  that the wound may, in reality, be
 lookedupon in the  light of a fistula.  In others, on the  contrary, the
 perineal opening closes up immediately, or in the space  of from eight
 to twelve days.  A patient  of M. Laugier recovered in this manner
in twenty days, though he had extracted from  him a calculus of more
than eighteen lines in diameter, by the bilateral operation.  Physick,
 Dorsey, and Copeland. in America, have each noticed an instance of
 this kind, and Beclard mentions several as the result of the bilateral
operation.  There  are  but  few distinguished  operators, in fact, who
 have not noticed a certain number of these cases; but no  person has
 published so  great a number as M. Clot, (Gaz. Med.,  1830, p. 176,)
 who relates eleven instances, either after the lateralized operation or
 Vacca's process of median lithotomy.

                §  VIII.—Recto-Vesical Lithotomy.

  The anxiety that operators have evinced at every epoch to avoid
wounding the intestine while performing  lithotomy, proves of  itself
how far they were  from wishing to create this incision  into an estab-
lished method.  Hence it happens that  it was not until within  these 
LITHOTOMY.
609
•latter years  that «.  suggestion  of this  kind presented itself to the
minds of practitioners, and that M. Sanson, who first ventured to
broach this sribject in 1816, (Des 3Ioyens de parvenir a la Vessie par
la Rectum, Paris, 1821, in 8vo.) found in this ancient prejudice one of
the greatest obstacles to the adoption of his opinions   Nevertheless,
it has been  since ascertained that the extraction of urinary calculi
through  the  rectum was not altogether a new process.  According
to M. Clot (Gaz. Mid., 1830, p. 167,) tradition speaks of it as a me-
thod  which  had existed in Egypt.  Vegetius, a veterinary surgeon
quoted  by Haller, had already said, a century before, in  his  work
published at  Bale: Jubet per  vulnus recti intestini et vesicce aculeo
lapidem ejicere.
   An observation made by F. Come, relative to a patient  in whom
the recto-vesical fistula was kept up by the presence of a  calculus,
and who recovered after the extraction of this body through the in-
testine, might have served also as a foundation for M. Sanson's the-
ory.  The fragment  of wood extracted from the bladder  by Cam-
per, by enlarging the fistula of the rectum, was another proof, which
might also have been adduced as an authority. Moreover  it is well
known that recto-vesical fistulas were  frequently  cured at the Hotel
Dieu by Desault, by incising the sphincter in such manner as to  form
it into a wound which should extend as far as to the perineum. How-
ever this may be, no person among us had laid it down as a princi-
ple that  we should pass through the rectum to search for vesical cal-
culi, and M.  Sanson  ought in reality to be considered as the inventor
of the  recto-vesical operation.  His  method, which never  found
many partisans in France, Germany, or England, was almost imme-
diately  adopted in Italy by a certain number of distinguished sur-
geons, among others by Vacca, and MM. Barbantini, Farnese, Gi-
orgi, Giudetti, Giuseppe, Lancisi, &c.  The advantages which were
ascribed to it are that of being an easy operation, and but little  pain-
ful, of opening the bladder at the widest part of the pelvic cavity, of
not exposing to the risk of wounding any artery, and of enabling us
to extract the largest sized calculi.  But the fear of having the  com-
munication of the  rectum with the bladder continue  after  the  cure,
has been a sufficient reason among us to outweigh all these probable
advantages.   The fact is, that even at  the present day, this process
of lithotomy  has scarcely ever been performed in our country except
by MM. Sanson, Dupuytren, Pezerat, Castara, Willaume, Cazenave,
Dumont, Taxil, Castel,  (Acad. Roy. de Med., 25th Nov. 1824; Arch.
Gen.  de Med., t. II.,)  and some others, that is to say, about thirty
times.
   A.  Operative process.—M. Sanson saw at the beginning that recto-
vesical lithotomy might be performed by two distinct processes ; the
one in which the prostate, urethra and the lower extremity of the
rectum are alone divided ;  the other, which attacks at the same time
the bas  fond, or rather the trigonus vesicalis, together with the in-
testine, and in  such manner as to respect the two  anterior thirds of
the gland.  In Italy,  Vacca and M. Barbantini  adopted the first more
especially, and to so great an extent, that  they in some measure ap-
propriated it to themselves.  Geri, Giudetti,  &c, adhered, on the
contrary, to the second, which is the one that M. Sanson had given
   vol. in.                    77 
610
NEW ELEMENTS OF OPERATIVE SURGERY.
especial preference to.   The  manner of performing both, however,
differs but in a very slight degree.
  I.  First process.—The sound held by an assistant, should press ac-
curatelv upon the median  line, and in such manner as to depress the
anterior wall of the rectum.   The  surgeon introduces the  left fore-
finger into the anus to the depth of an inch; turns its nail backwards
and pulp forwards; glides in flatwise upon this finger a sharp-pointed
bistoury, and after having turned its  cutting edge  upwards, inserts
its point into the groove of the sound; then elevates the wrist of the
right hand, and divides the recto-urethral triangle from behind for-
wards, that  is  to say, from the intestine towards the urethra; and
afterwards endeavors to find,  at the bottom of this wound, the pros-
tate, and through the membranous portion of  the  urethra adjusts his
finger, whose ulnar border should look towards the symphysis pubis,
and its  nail towards the left  ischium, on the groove of the  sound.
The same bistoury, held as a writing pen, is  then inserted into  the
groove of the directing instrument, and afterwards glided along this
groove into  the bladder.   It is then withdrawn while depressing the
hand a little in order to dfvide from  before  backwards, almost  the
entire prostate, together with  the other soft parts which might possi-
bly have escaped at the time of the first incision.   In this process,
we divide the external sphincter,  the intercussating fibres  of  the
transverse and  bulbo-cavernous muscles, the point of union of  the
different fibrous laminae  of the perineum, the  prostate from its apex
to its base, and the front part  of the rectum underneath the trigonus
vesicalis.  One of the ejaculating ducts is also comprised in the inci-
sion, for it could only be by accident alone that the bistoury could be
conducted with such precision upon the  median line as to enable us
to fall exactly between the two ducts.   If,  as might very readily
happen, the  incision should deviate  too much  upon the side, it would
soon reach upon a point remote from  this canal, or might even  fall
upon the termination of the vas deferens, and finally upon the lower
extremity of the corresponding vesiculum seminale.   As to  the rest,
no important artery presents  itself, not even the  abnormal branches
mentioned in speaking of perineal lithotomy.  In place of the opera-
tive process of M. Sanson, Vacca proposes that the right forefinger
should be applied in such manner upon one of the sides of the bistou-
ry, whose handle is grasped by the same hand, that in slightly press-
ing its pulp  against it, it may cover  the whole point of the  instru-
ment ; that the whole is to be introduced in this manner to the depth
required; that having reached there, the cutting edge of the bistoury
is to be  turned forwards, in order that the finger may be placed be-
hind it upon its back, and that the section of the tissues should be made
by a single cut, as has been just described; the left forefinger, which
had remained free, is immediately to be  placed upon the groove of
the sound, in order that the bistoury, whose edge is then to be turned
downwards, may be  directed  upon the  membranous portion of the
urethra, and thus divide the prostate and  border of the vesical orifice
from before backwards, that is to say, in a direction opposite to that
which it had followed up to that moment.
   II. Second process.—The  first incision, which commences a little
higher up, does not terminate as near the bulb of  the  urethra in  the 
LITHOTOMY.
611
second as in the first  process.  It  is no longer the apex, but in fact
the base of the prostate, that the left forefinger re-introduced into the
wound now endeavors to find, and it is on a line with the posterior
border or at most at the point of union of the two lower thirds with
the upper third of this gland, where the  bistoury should be plunged
in to reach the groove of the director; it is afterwards to be pushed
into the bladder, in order  to lay open its lower wall to the extent of
about  an inch, withdrawing  the instrument from  behind forwards,
and slightly from  above downwards.  The  solution  of continuity
when we adopt this method falls, in so far as regards the first incision,
upon  the same parts as in the  preceding.  The second stage of the
operation, on the contrary, avoids  those portions of the urethra  and
prostate which receive and are traversed by the seminal ducts, and
attacks the trigonus vesicalis in its place, while approximating in a
greater or  lesser degree to the  recto-vesical cavity.   Should the
incision not be made  precisely upon the median line, it might wound
the ejaculating ducts, the vesiculse  seminales and the vasa deferentia,
and even the urethra.  It is  also  perceived that the  peritoneum is
exposed to  a very considerable degree of danger, and that it could
not be avoided should it descend a little lower than usual.  It is  also
to be  remarked  that in  consequence of the direction given to the
bistoury while  it is being withdrawn from the bladder, the wound
must fall to a much greater extent upon the last organ than upon the
intestine,  and that it is consequently prolonged much  higher on the
inner surface of the bladder than upon that of the  intestine;  so that
the mucous  membrane and a great portion even of the muscular coat
of the  rectum will descend  in the form of a  projection or valve, to
the distance of several lines below the wound in the bladder.   Some
Italian surgeons have supposed  that M. Sanson's  process might be
improved by placing  a dilating instrument in the interior of the  rec-
tum.   It was with this view that M. Geri, for example, had proposed
a large gorget.  At  first view a modification of this kind would
appear to possess the advantage  of diminishing the mobility of the
tissues, which M. Pezerat had so  much difficulty  in overcoming in
the recto-vesical operation as  performed by  him, and  to have the
advantage also of actually giving greater facility to the  incision.
Vacca, however, has vehemently opposed this modification.  It must
be  readily perceived, in  fact,  in  reflecting upon  it, that it would
increase the difficulties of the operation instead of  diminishing them.
However, it is not in respect to its mode of execution that objections
may be raised against  lithotomy by the rectum.   All the ameliorations
proposed in reference to this point are not in  reality of a character
to deserve any particular attention.
  B. If we  should be disposed  at the present time to form  a  just
appreciation of the value of recto-vesical lithotomy, we could do so,
as it appears to me, without any difficulty.  Its first advantage, and
the most indisputable of all, is that of protecting us from hemorrhage;
the second is that  of possessing an  extreme degree of simplicity.
We should  not  however deceive ourselves  on  this  point.  The
division of the mucous membrane of the  anus, of the walls of the
intestine, and even of the posterior portion of the perineum, is at-
tended in certain patients with all those difficulties which are pointed 
612
NEW ELEMENTS OF OPERATIVE SURGERY.
out by M. Pezerat, whatever may be the precautions we adopt to
stretch the tissues.
  In opposition to those who accord to it the advantage of affording
so easy an egress to the urine that we haVe  no cause to fear infiltra-
tion, it may be stated that the recto-vesical septum, drawn upon by
the instruments or by the stone during the operation, is  sometimes
liable to be lacerated, and  that in such cases we  cannot perceive
what would prevent the effusion of some drops of urine into the sur-
rounding  cellular tissue.  There is another objection, which is this,
that from the infiltration taking place above the  pelvic aponeurosis,
it would  very quickly spread to the sub-peritoneal cellular tissue of
the pelvis.  The advantage, which  it is alleged to have, of allowing
of a large incision and the extraction of enormous calculi, may also
be contested.   It  is a  grave error, in  my opinion, to refer the  diffi-
culties in such cases to the degree of distance existing between the
bones.   I cannot  conceive any more than  Scarpa how, in any pro-
cess of lithotomy  whatever, the  lower strait, should it be  of regular
conformation, could present an obstacle to the extraction of a stone.
It  is at the opening made into the bladder where  all the embarrass-
ment lies.  When this opening is directed exclusively upon the bas
fond, we are not enabled to give it  more than from  twelve to fifteen
lines, because there is only this distance between the  prostate and
the cul de sac of the peritoneum.   Whence then is the advantage,
since in  bilateral  lithotomy, for example, we may obtain an opening
of from fifteen to twenty lines ?  If we limit  ourselves to the incision
of the prostate  with the expectation of not going beyond its limits,
the division can have but from eight to twelve lines, even supposing
we give it its  greatest extent.   If we give it a  greater  extent We
necessarily go beyond the border of the gland, because in this direc-
tion there is only  from six to seven lines of it to divide ; if we should
unite the two processes, the opening might be extended to an  inch
and a half or two inches; but up to the present time this has been
proposed  by no one.  Bilateral lithotomy, moreover, could also fur-
nish us as extensive a division.   Finally, if we no longer  adopt the
rule which directs us to  confine ourselves  to the  periphery of the
prostate, it is evident  that we might, by the bilateral method, incise
the neck of the bladder upon each side, in such manner as to obtain
a wound  of two or two and a half inches in extent; which  would not
be possible in the  recto-vesical operation but by voluntarily exposing
ourselves to the risk of wounding the  peritoneum.  It would appear
that in speaking  of this process some importance has been attached
to the division of  the perineum and membranous  portion of the ure-
thra.  The same error also is found in  almost all the discussions in
relation to the other kinds of cystotomy.  Nevertheless, it is easy to
perceive that in regard  to the passage of the  stone, there is nothing
else but  the enlargement  of the posterior  opening of the urethra
which can be taken into the account as of any value.  Thus enlarge
it directly backwards  and  you will never obtain  any more than an
opening of seven  to eight lines unless you  go beyond the prostate •
whether  the exterior incision be confined to the  perineum, or whe-
ther it includes at the same time the extremity of  the  rectum   In
prolonging this incision an inch or an inch and  a half farther' you 
LITHOTOMY.
613
will  traverse the whole extent of the trigonus and will give to the
wound a length of only about two inches, while at the same time ex-
posing yourself to the risk of wounding the peritoneum.   The double
oblique incision, on the contrary, enables us to go to the extent of
twenty lines or more without encroaching upon the apex of the blad-
der,  and  if you are not afraid of going beyond the prostate you will
evidently be enabled still to increase the dimensions of the wound to a
much greater extent than by the posterior method.  As to the lesion
of the arteries, the point to  ascertain is, whether this can counterbal-
ance the danger of recto-vesical fistulas.
   In transversal lithotomy  it is almost certain  that hemorrhage can-
not take  place in  one case out of 100 ; while the recto-vesical ope-
ration is  followed by a urinary fistula, at least in  one  case out of
every four or five.  The hemorrhage also is far  from being always
fatal, while the  fistula is  a  disgusting  infirmity, which  is in most
cases incurable.  The recto-vesical  operation has  furnished, up to
the present time,  almost as great a proportion  of deaths as the pro-
cesses of perineal lithotomy.  It possesses in a special  manner the
disadvantage of unavoidably wounding one of the ejaculatory ducts.
Experience has shown that it frequently causes enlargement of the
testicles, and serious affections  of these organs.  In one of the pa-
tients of  M. Geri, (Arch. Gen. de Med., t. XII., p. 236,) the duplica-
ture of the perineum  was laid open.   M. Janson, (Mem. de la Soc.
Med. de  Gand., 1835, p. 93,)  lost two patients  out of six cases.  The
intestine  was found to  be inflamed to an intense  degree.   Many au-
thors show that  the  bladder has  been  frequently inflamed by the
passage of stercoral matters into this organ.  Scarpa  states that it
gangrened in two cases  noticed by him.  The  vesiculae seminales
have also been  laid open, and purulent collections in  the  interior of
the pelvis have been met with in a great number of instances.  Fi-
nally, out of about 100 operations of this kind,  which appear to have
been performed up  to the present time, by MM. Sanson, Dupuytren.
Camoin,  Pezerat, Willaume,  Cazenave,  (Bull. Med. de Bordeaux.,
1833, p.  121,) Dumont, Castara, Urbain,  Janson,  Taxil, Barbantini,
Vacca, Geri,  Orlandi, Gallori, Mansfredi, Guidetti, Farnese, Giorgi,
Guiseppe, Cittadini, Mori,  Lancisi, Castaldi, Cavarra, Regnoli, Ban-
diera,  (Bull,  de  Fer., t. II., p. 156,) Heihg,  (Ibid., t.  I., p.  346,)
Fasoti, (Ibid., t. I., p. 352,) Meli, Clot, (Compte rend, de VEcole de
Mid. d'Abou-Zabel, Paris, 1832, in  8vo.)  Wenzel, (Bull, de Fer.,
X. VI., p. 280,) Dawson, (S. Cooper, Diet., p 15, 7th edit.,) and Lal-
lemand,  Lafosse, (Ephem.  Med. de  Montp., Dec, 1828,) we count
about 20  deaths, the same number of fistulas, and a variety of acci-
dents which have placed the life  of some of the other patients in
danger.  The  following table  moreover,  (Extrait du  Journ. des
Chir. von Graefe und Walther, achter  band, scite 540, par M. A.
Belin,) will furnish a complete detail  of these cases. 
RECTO-VESICAL   OPERATION   FOR   STONE
                First.   Cases followed  by  Complete  Cure.
Operators.		Age
Camoin,		20
Pezerat,		17
Dupuytren,	3	11
Vacca,	3	38
Vacca, Vacca,	4 5	74 38
Vacca,	6	2
Vacca,	7	60
Vacca,	8	46
Vacca, Vacca, Vacca, Vacca,	9 10 11 12	11 12 15 65
Vacca, Vacca, Vacca,	13 15 17	8 6 14
Vacca,	20	6
Operative
 process.
1st process,

   ditto,  j


2nd process.
•S
Size and weight of the
      calculus.
 Escape of fecal
matter through the
     urethra.
weight, 2 ounces,
Length  21 lines,  breadth
  1 inch,
medium size,

size of a pigeon's egg,

50 small calculi,
size of a large pigeon's egg,
  with a prolongation,
length 10 lines,
breadth 3 lines,
weight 4 ounces,
medium size,
2 calculi of medium size,
tolerably large,

sized of a pigeon's egg,
very large,
19 lines in its long diame-
  ter,
length 1J inch,
breadth  11 lines,
frequent,

none,
occasional,
Duration of
 treatment.
less than two
   months,
  about two
   months,
52 days,

30 days,

25 days,
1 month,

14 days,


60 days,

4 months,

22 days,
1 month,

22 days,

12 days,
35 days,
6 months,
Remarks.
2 months,
The cure was retarded by the complication of catarrh of the bladder.
  Complicated with diarrhea, dysentery, pyuria or purulent urine, or he-
maturia.

  The stone broke into pieces, the appendix being of the size of the little
finger.
  The stone was broken.   An habitual stricture of the urethra retarded
the cicatrization.
  The stone was broken.   A sickly constitution and urethral coarcta-
tions retarded the cure.
  About eight days after the operation the testicles swelled up in conse-
quence of the patient's going out.


  Of a scrofulous appearance;  weak health, purulent urine, pain ex-
tending as far as the left kidney.  After the operation, he had nightly
attacks of fever, and a large quantity of gravel was evacuated by the
urethra, and through the wound.
  On the 30th day from the operation, after  making a violent effort to
urinate, the wound burst open.   The urine contained much gravel.
OS 
First.   Cases  followed by Complete  Cure.—Continued.
Vacca,

Vacca,
Vacca,

Giorgi,
Giorgi,
Giorgi,
Giorgi,
Giorgi,
Giorgi,

Giorgi,

Giorgi,
Giorgi,
Cittadini,
Cittadini,
Farnese,
Barbantini,
Guiseppe,
Camici,
Geri,
Janson,
Janson,
Janson,

Janson,
Orlandi,
Bandiera,
21  16
22
24

 2
 3
 4
 5
 6
 7
8  12
53
 75
yth.
 i<
  3
7 m-
 30
2nd  process.
lst&2dproc
2nd  process.
2nd  process,

2nd  process,
    ditto
2nd process,
   ditto
 1st process,
   ditto
   ditto
   ditto
lst&2dproc.
small, fragile,

size of a small nut,
size and  shape of an al-
  mond,

very large,
size of a pigeon's egg,
larger than a pigeon's egg.
         ditto
2 calculi, each the size of
  an almond,
size of a hen's egg, weigh-
  ing 2 ounces,
weignt, 6 ounces,
the size of a nutmeg,
medium size,

weight, 1 ounce,
breadth, 3 inches, 3 lines,
  length, 2J inches,

size of a hen's egg,
          ditto
          ditto
          ditto
          ditto
round, \ inch diameter,

tolerably large size,
3 calculi, the  largest of
  which was the size of
  a small nut.
small calculus,
none,
    none,
a small quantity
  of liquid faecal
  matter,
  none,
fecal matter,
     ditto
     ditto
     ditto
45 days, *

36 days,
12 days,

20 days,
2 months,
12 days,
17 days,
24 days,
nearly 1 mo.

about 34 days,
8 days,
20 days,
12 days,
80 days,
30 days,
20 days,
  ditto
6 weeks,
5 months,
about 55 days,
17 days,


45 days,
  Some drops of urine  only issue through the wound, a  few day« j
before the ordinary time.




Unequivocal symptoms of a diseased bladder


The stone was extracted by means of the fingers.


The urine was turbid, sanguinolent, purulent, and of an infected odor.

  The size of the stone obliged the operator to crush it in the bladder,
with which (as was seen afterwards) it had several adhesions. There
followed some inflammatory symptoms, which were subdued by bleed-
ings.
  On the discharge  of this patient,  there still remained a  fistula,
which closed up subsequently.  A fistula of the rectum, which was the
result of a previous lateral operation, also got well at the same time. 
First.   Cases followed by  Complete  Cure.
Regnoli,
Moschi,

Moschi,
Moschi,
Malori,
Galnfredini
Cavarra,
Cavarra,
Cararra,

Cavarra,
Cavarra,
1 73
Cavarra,
Cavarra,

Cavarra,
60
62
53
71

 9
2i
 9

10| 60
lst&2d proc. 13 calculi,
2nd  process,  the size of a large nut,
ditto
ditto
In his first 5
casesCavarra
modified the
 2nd opera-
tive process.
2nd process
3 calculi each an  inch in
  diameter,
 10 calculi, the largest of
   which was the size of a
   small nut,
 shape and size of a small
   nut,
 size of a small nut,
 the calculus, was broken
   into several pieces,
 2 large calculi,
 large,  and  was   broken
  into pieces,
2 calculi  of 2 inches  in
  their great diameter,
matter passed,
40 days,
a little over a
  month,
14 days,
12 days,
in the space of
about a month,

in the space of
   20 days,
18 days,
18 days,

about 20 days,
19 days,

25 daysr
  The calculus was adherent on one side.
  The patient had vesical fistulas and strictures of the urethra, which
after 15 days caused the urine  to fltiw anew through the intestine;
the use of an elastic bougie soon made all right again.
  The operation could not be performed in consequence of deformity
of the pelvis.
  This patient had been operated on by the first process.   A fistula
which had been the result of it was cured on this occasion.
Vacca,	2	5	2d process,
| Vacca,	23	2	ditto,
Giorgi, Cittadini,	1 3	28 7	1st process, 2d process,
Second.    Cases followed  by Fistula

    none,           48 days,
medium size,


small calculus,
some escape,

    ditto,
none,
18 days,

27 days,
  The fistula was  almost closed on the day that the operation was
published.
  The escape of fecal matter through the urethra in this case might be
attributed to the too prompt re-union of the sphincter ani.
  Some drops of urine escaped through the fistula.
  A few drops of urine escaped by chance.
01 
Second.    Cases followed  by Fistula.—Continuea.
Cittadini,	5	70
Mori,		50
Cliet, Geri,		12
Dupuytren,	1	57
Dupuytren,	2	—
Cavarra,	1	70
2nd  process,
  combined
with the first,
   ditto,

2nd process,
Vacca asserts
 that  Geri
 adopted the
 1st process.
large calculus,


2  calculi,   weighing  9
  ounces,
size of a small nut,
size of a large nut,
Broken in pieces.
matter escapes,

no matter obser-
  ved to escape.
quite frequent,
30 days,
25 days,
about a month,
The patient died of tubercular phthisis 3 months after the operation.
  This patient had already been twice operated upon for stone, and
there remained a fistulous opening after the first operation.
  This was the preceding case, after an interval of six months.  This
operation must have succeeded like the first.
  Frequent contraction of the urethra.
Third.  Cases followed  by  Death.
Operators.
Dupuytren,


Vacca,

Vacca,


Vacca,
	Age.
4	13
1	70
14	6
16	55
Operative    Size and weight of the   Ti    f d  th
 process.          calculus.
2nd  process.

   ditto,


   ditto,
2 inches 4 lines,
1   "   8   "
1   "   4   "
very long,

size of a pigeon's egg,


medium size,
on the 36th day,


   "   4th day,

   "   8th day,
About 2 months
  after the ope-
  ration,
Remarks.
There was a vast abscess between the rectum and bas fond of the bladder.
  Inflammation of the lower belly.  Gangrene of the internal surface of the bladder
to which the stone adhered.
  During the night following the operation, pain in the hypogastric region;  fever
came on, and went on constantly increasing.  The post-mortem examination showed
traces of inflammation in all the organs contained in the pelvis.
  At the time of his entrance the patient was very thin.  A diarrhea set in, and a
short time after there was jaundice to a certain extent, but death occurred without
being preceded by distinctly developed evidences of the disease.  The examination
after death showed the bladder  and organs contained in the pelvis in their normal
condition.  The wound of the neck of the bladder and of the prostate had healed ;
only that of the membranous portion of the urethra remained  uncicatrized.  The
two ejaculatory canals were entire; either they had not been divided, or  had healed.
The substance of the liver had been transformed into tuberculous and scirrhous mat-
ter ;  this organ was atrophied, whilst the gall bladder was much larger than usual. 
Third.  Cases followed by Death.—Continued.
Vacca,
Vacca,
18
19
Cittadini,

Barbantini,
Geri,
Janson,  )
Janson,  J
Janson,
Regnoli,
Martini,
Meli,
Cavarra,
56
55
   70

quite ad-
 vanced,

child,
children,
   26
   79
    7
12
2nd  process,
2nd  process,

1st process,
2nd  process,
ditto,
adult,
2 lines  in diameter,
  and by  which the
  stone  was extract-
  ed,

2 calculi of consider-
  able size,
extraordinary size,
very large,
the size  of a hen's
  egg, 3 J ounces,
on the 11th day,
6 hours after,
40 hours,

24 hours,
24 hours,
15 days,
3 days,
10 hours,
  Robust constitution, sanguine temperament, extraordinary embonpoint.   On the
16th day there was fever and delirium, and three exacerbations of fever daily.  The
autopsy showed that the intestines, peritoneum, and the other abdominal and pelvic
organs were without traces of inflammation or any other lesion.   The wound was
situated between the seminal ducts, neither of which had been touched.
  This patient was of a robust constitution; he was in the habit of taking opium.
Shortly after the operation and again a little later, H grains were given him.   There
followed irregular movements of the muscles of the face, with paralysis of the extre-
mities and coma.  By the autopsy, the prostrate, which was found much larger than
in its normal condition, projected about  an inch into the bladder,  and separated the
fundus from the neck of that organ in such a way that the fundus had quite the ap-
pearance of a sac which could have contained two stones.
  This patient died during an attack  of epilepsy ; an  effusion of blood was found
within the cranium.
   Subsequently to the operation, all  hope was lost, in consequence of an internal
pain which showed itself in the bladder.  The urine contained fecal matters.  Peri-
tonitis took place afterwards.
   The peritoneum was wounded.

   Intense peritonitis.

   An ulcerated bladder, and its internal surface covered with gravel.
   The stone could not be extracted in consequence of its size and adhesions.
   Died in consequence of the incessant and obstinate reproduction, in spite of every
remedy, of a large quantity of worms, which terminated in a  slow and obscure
pneumonia.  The lymphatic ganglions,  especially those of the lower  belly, were
hypertrophied.
   A short time after the operation, inflammatory symptoms appeared. Autopsy: The
prostate projected like a uterus.  The ureters  were four times the natural size, and
full of pus.  The kidneys presented the same appearance, having their tubular and
cortical portions destroyed.
   A strong constitution and sanguine temperament.  The operation was easily in-
formed.  On the ni<jht  after the operation, there was intense pain in the bladder,
fever, suppression of urine, black vomiting. Autopsy: The bladder large  and  in-
durated, somewhat cartilaginous, the bottom of the wound mortified, the right ureter
and kidney inflamed. 
LITHOTOMY.
619
               § XL—The Hypogastric Operation.

  We do not find in the ancient authors any definite expression in re-
lation to the operation of opening into the bladder above the pubis,
in order to extract calculi from it.  It appears certain that Philagrius
in recommending that we should incise superne juxtd glandis mag-
nitudinem, merely intended to speak of calculi arrested in the urethra,
and that in opening into the dorsum  of the penis, his only object was
to prevent  fistulas, which were much more to be  apprehended when
the incision was made in  the lower wall of the urinary passage.  On
the other hand, we cannot find what grounds M.  S. Cooper has for
supposing that the operation performed by Collot in 1475, had refer-
ence to the hypogastric  operation rather than to nephrotomy, or to
any thing else  we please.  It was  unquestionably Franco to whom
we are indebted for  this process; and this practitioner also was led
to it, so to speak, in spite of himself,  and is careful to warn others
against imitating his  conduct.  Rousset, who gave a detailed descrip-
tion of it in 1581, 20 years after the  publication of Franco's work, is
therefore the first person  who positively recommended it,  and who
endeavored to have it adopted as a  general  method.   Nevertheless,
the manner in which he mentions it, would induce us to believe that
other physicians also at his time had  spoken of it.  However this may
be,  Rousset, in consequence of the death of Henry III.,  who had
promised to assign to him three or  four  criminals, in order to make
trial of it, was not enabled to perform it upon the  living body, and no
person appears to have thought of it since his time up to the epoch at
which  Mercier undertook to defend  it at the  faculty of Paris, in  a
thesis of N. Pietre, in 1635.   Some  surgeons finally adopted it, and
Collot relates that in  1681, Bonnet, of the  Hotel Dieu, had performed
it with complete success,  in the presence of Petit.  Some years sub-
sequently, Proby, from finding himself unable to  extract a calculus,
through the usual routes,  also had recourse to it,  and Groenvelt, in a
work  published at  London  in  1710, declared himself its  avowed
champion.  Nevertheless, it was still so little known, that Douglas,
in 1718, at one moment supposed himself to have been the inventor of it.
The successful results which this last surgeon obtained from it, having
finally opened  the eyes of practitioners, hypogastric lithotomy soon
became a subject of investigation with Cheselden, MacGill, Thornill,
Middleton,  Bamber, and Pye, in England.  Morand, who made trial
of it at the  Invalides on the 27th May, 1727, on an officer 68 years of
age, saw it performed on  the 10th December following, by Berier, at
St. Germain-en-Laye, on  L.  Amon,  who was four years of age.  It
was also performed by J. Robert, Sermes, Kulm,  and Heuermann,
and especially  by Heister, who defended it in a thesis, supported by
Weise, at Helmstadt, on the  8th September,  1728, and who cited in-
stances of it from Runge  and Prsebisch, so that it appeared to be on
the  point of being generally, adopted.  In 1727, Cheselden, who had
performed  it on 6 patients, had yet lost but one, and Douglas also one
only, out of 9 cases.   Out of 12 cases, Thornill  lost only two, and
MacGill but one out of 4.  Nevertheless,  the great excitement pro-
duced  by the appearance of  F. Jacques, soon  caused it to fall into
disuse, and there was scarcely anything more said of it until F. Come 
620
NEW ELEMENTS OF OPERATIVE  SURGERY
in his turn undertook to bring it into repute, in 1775.   From that time,
Le Blanc and Bazeilhac declared themselves its partisans.  Lassus,
as well as Deschamps, Dupuytren, Boyer, M. de Guise, and several
others, also occasionally had recourse to it, but only in the character
of an exceptional method.  Notwithstanding all the justifications that
had been employed in its defence, and the  numerous successful re-
sults which had been obtained from it in France, by M. Souberbielle,
the inheritor of the principles of F. Come and  Bazeilhac, the high
operation had again fallen into disrepute, until in consequence of the
improvements proposed by Scarpa, Dupuytren, Everard Home, and
Gehler, it was a third  time  attempted to  demonstrate  its  advanta-
ges, and to substitute it for the perineal methods.  It consists  of an
incision into the anterior wall of the bladder, through the parietes of
the abdomen.
  A. Examination of the methods.—The high operation has not pre-
sented  as many methods  as  perineal lithotomy, and the  processes
which belong to it can scarcely be considered in  any other light than
as modifications of each other.   In order to analyze them with some
degree of method, I classify them under  three  different heads.  In
the first,  we operate without the previous introduction of a director.
In the second it is directly the reverse ; while  the third is distinguished
from the  two others in this, that we make an accessory opening below
the pubis.
  I. Method of Rousset.—The first method  of performing hypogas-
tric lithotomy, is the one recommended by Rousset.   We  begin by
injecting  barley water, tepid water, milk,  or in  fact any vulnerary
decoction into the bladder, in order to distend it, and to oblige it to
project above the pubes.   In  order that the liquid  may not escape
contrary  to the intention of the operator, a ligature is placed around
the penis of the patient, or an assistant is  directed  to compress it.
The integuments, and the  aponeuroses are incised  upon the median
line by means of a razor.  A  bistoury which is slightly concave, is
then introduced  obliquely downwards and backwards between the
symphysis and the bladder, with its back turned  towards the  bones,
in order to open into this  organ with considerable caution.  Should
the puncture be very large, the bladder would be immediately emp-
tied.  It  is necessary that  it should be sufficiently so only as to ena-
ble us to  introduce a lenticular bistoury, by which the wound is to be
immediately enlarged from below upwards, but in such manner how-
ever, as not to go as far  as the peritoneum.  The stone  finally,  is
extracted by  means of the fingers  alone, or  by the fingers wrapped
in linen, or by the scoop or tenacula.
  a. Douglas has modified the process of Rousset in two respects.
He recommends that the organ should be  but moderately  distended
by the injection, in order that it may not incur the risk of having its
fibres paralyzed, and because its  excessive  distension is in most cases
insupportable.  He substitutes a  convex bistoury  for the razor.   The
straight bistoury, which he employs in preference to the curved, en-
ables him at the same  time to make  the puncture  into the bladder
and also  to enlarge this wound immediately without having recourse
 o the  probe-pointed bistoury.
  b. Cheselden. who  also does not like any  great  distension  of the 
LITHOTOMY.
621
bladder,  recommends the  patients to retain their urine as much as
possible,  and that we  should inject only a quantity of liquid equal to
that which  they ordinarily discharge.  When  he has laid  bare the
aponeurosis with a convex bistoury, and divided  the linea alba with
a straight  bistoury, he prefers  a  concave bistoury,  and not probe-
pointed,  for opening into the bladder from above downwards, and
no longer from below upwards, as is recommended by Rousset and
Douglas.   The curved scissors, recommended by MacGill in place
of the bistoury at this last stage  of the operation, would expose us
too much  to the  danger of wounding  the  peritoneum, to allow of
their adoption, and are in every respect of too little advantage to ren-
der it necessary that we should examine a modification of this kind.
  c. Morand scarcely modified the process of Rousset except in this,
that he made his  patient  lie down in the opposite position, with his
head and chest lower than  the pelvis, and his legs secured to the
posts of  the bed.   He also insists upon the danger of forced injec-
tions, and  endeavors, moreover, to  show their inutility.   With him
the straight bistoury for the incision of the  abdominal walls, and the
concave  bistoury for  the bladder, were found quite sufficient.  It is
to him we  owe the suggestion  of making use of the left  forefinger,
bent into a hook, in order to retain the bladder at the upper angle of
the wound, while we completed its division, as had also been recom-
mended  by Heister.
  d. Others, and Le Dran in particular, considered that in place of
incising the bladder from above  downwards, it would be better to
divide it  transversely, and that  by acting in this  manner, we should
run less risk of wounding the  peritoneum.  Winslow alleged that
we might dispense with injections by making the  patient drink freely
of a diluent ptisan for some weeks before subjecting him to the ope-
ration, and pointed out to Morand that the position chosen by this
last  was  but little suitable.   According to him, Thibaut, of the
Hotel Dieu, had suggested the idea of returning  to the incision from
below  upwards, and recommended,  like La Peyronie, that we should
plunge the  bistoury into the bladder with one  movement, in such
manner as  to divide the whole thickness of the  tissues while with-
drawing  the instrument.   Lecat followed this advice in the two pa-
tients upon whom he  performed the high operation.   His cystotome
bistoury  introduced by puncture, with  its back turned downwards,
enabled him to divide  the bladder above, and then to retain this organ
momentarily suspended by means of a projection on the convex bor-
der of the  bistoury, and  which was suddenly turned round in this
direction until the surgeon had replaced it by a suspensory hook.
  e. In these latter times the process of Rousset has again under-
gone some  modifications.  M. Baudens  says he  has done very well
without  introducing any liquid  into the bladder,  and in laying bare
this  organ  a little  towards its side, as  had already been recom-
mended  by Pietre, Solingen, &c, also in introducing the left fore-
finger  down to the posterior side of the pubes,  in order to crowd
back the peritoneum from below upwards, and to make tension upon
this membrane at the same time as upon the bladder; then to plunge
the bistoury into the  cavity of this organ  from  above downwards,
arid immediately  to introduce the finger into  it  in the manner of 
622
NEW ELEMENTS OF OPERATIVE  SURGERY.
Morand, continuing the incision in the same direction without stop-
ping down to near the neck of the bladder.  M. Baudens (Bull, de
Fer.] t. XX.,  p. 224) also thinks that we should incise laterally the
rectus muscle as well  as the lips of the wound  of the bladder, as
had already been  done or  recommended by MacGill and Le Dran,
when any difficulties presented  themselves in regard to the extrac-
tion of the calculus.
  /. M. Tanchou  has  supposed that he  could  render this  process
more easy  by using a species of flattened trochar with a sheath,
grooved on one of its borders, and  a joint at a certain distance from
its extremity, and the rod in which, having a cutting edge, tranforms
it  into a bistoury. The operation is performed in the following
manner.  The operator  incises upon the median line down to  the
front of the peritoneum, by  means of a convex bistoury.   By means
of the left forefinger introduced into the bottom of the  wound, he
recognizes the fluctuation of the bladder, which has been moderately
distended by an  injection of tepid pater ; then plunges in his instru-
ment from  above downwards and  from before backwards ; with-
draws  its cutting blade  by means of  a spring ; when its sheath
immediately bends into  a  right angle,  forming a suspensory hook
developed in the  interior, and  upon the lower border of which a
probe-pointed bistoury is to be conducted, in order to enlarge  the
wound.
  g.  Finally, M.  Verniere (Bull, de Fir., t. XX., p. 224) has con-
sidered  that  he  has introduced  an advantageous  modification  into
practice, in proposing a previous operation, which consists in  incising
the hypogastric wall in order to introduce between  it and the front
part of the  bladder a plate which is destined, by acting from  behind
forwards, to compress  the peritoneum against the inner side of the
recti muscles  during  the space of several  days.   The adhesions
which result from this compression will  enable us, he says,  to open
into the  bladder without  the slightest danger of penetrating  into the
cavity of the abdomen.  A suggestion similar to that of M. Verniere
has been communicated to me by Al. A.  Vidal.  This surgeon  pro-
poses  to  perform the  operation in two  stages, with an interval of
several  days between.  The  first, which  consists  of  an  incision
through the tissues, which separates  the bladder from the external
surface, has for its object to render the  cellular layers impermeable
by inflaming them. The second consists in opening into the bladder,
which, according  to the author, will by this means be no longer
exposed to urinous infiltrations.
   h. Appreciation.—There is  not one  of all these modifications
which  in  reality deserves  an  absolute  preference  over  the others.
That of Morand, so far as  regards the operation  properly so called,
is, as it appears to me, the most prudent.   To make the patients re-
tain their urine in order to distend their bladder, is  a thing which
may be  more easily  recommended  than carried out.  All  that is
necessary to  convince  us of this is to recall to mind how frequently
calculous  patients have  an inclination  to  urinate.  The injections
could not, in  fact, be supported  if we persisted in throwing them up
in such quantities as to make the bladder  project above the pubes.
But  in  the majority of cases we have  no difficulty  in giving  it  a 
LITHOTOMY.
623
 moderate degree of distension by the injection of an emollient liquid,
 which is sufficient to enable us easily to recognize its presence behind
 the pubes by means of the finger  introduced through  the  wound at
 the linea alba.   As to the nature of the liquid to be injected, milk, to
 which  Middleton appears  to  give the  preference, and  of  which
 Rousset himself had already spoken, is evidently, on account of its
 tendency to decomposition, less suitable than mallows or barley water,
 or better than  all these, a certain quantity  of tepid water.' Air,  the
 suggestion of  which  is  ascribed  to  Solingius,  (Theses de Halter,
 French transl., t. II.,) though already mentioned by Rousset, when
 he says that it  was recommended  in his  time to fill the bladder with
 wind, would possess no advantage over any liquid whatever, and
 merits  the little importance that was given to it.   As to  the precept
 of Bamba, who recommends that the injection should not be thrown
 up until after the incision made througn the linea alba, and that  of
 Middleton, who thinks that we should at least then throw up a little
 more than before commencing the operation, they  have been long
 since rejected.   The incision from below upwards with a straight
 bistoury, as in the  process of Douglas, or with  the probe-pointed
 bistoury, according to Rousset, would enable us, if necessary, to take
 a point d'appui against  the pubis and  to proceed with a certain
 degree of security; but it  is undeniable that we would in this way
 incur too great a risk of perforating the  peritoneum, and of opening
 into  the belly, as was remarked  by  Cheselden.   In  adopting the
 incision from above  downwards it  is almost a matter of indifference,
 provided we are sure of our hand, whether we  prolong it with the
 scissors or with  the probe-pointed, straight or  curved bistoury,  or
 with  the  ordinary straight  bistoury.  The  transverse  division  of
 the bladder would have the inconvenience, as Winslow remarks,  of
 presenting a wound  which would  be  perpendicular  to  the  direction
 of the external incision, and which, by retracting behind the pubes,
 would peculiarly expose to the danger of urinary infiltrations.  It is
 also  very evident that the lateral incision of the recti  muscles,  as
 practised  by Pye, and at  another time  by Dupuytren, and which
 Gehler  in our time has proposed to establish as a rule, is not  appli-
 cable except in those rare  cases  in which spasmodic  contractions
 take place in so violent a degree as to prevent the introduction of the
 fingers  or tenacula  into the bladder  through the wound, as I saw
 occur in a patient operated upon by M. Roux at  La Charite in 1827.
 The  process of M. Baudens would have the serious inconvenience,
 by detaching the peritoneum  of causing too extensive  a laceration
of the cellular tissue.  There can be no doubt that in those cases  in
which  the bladder has entirely receded to the bottom of the pelvis,
the operation would  be attended with very considerable difficulty if
no injection was used.  The bare mention of the suggestion of M.
Verniere is  sufficient of itself, as I consider, to enable every one  to
appreciate it at its just value.  That of M. Vidal is more simple and
more  rational.  As to the combination of M. Tanchou, its prudence
cannot  be  questioned; only as it exacts a particular  instrument
which  has no other advantage than that of enabling us  to introduce
a hook into the  bladder, at the same time that we penetrate into it by
the puncture, and as the  puncture into  this  organ, by means of a 
624
NEW ELEMENTS OF OPERATIVE SURGERY.
bistoury, enables us almost always  immediately to introduce into it
the finger or any suspensory instrument whatever, this process I pre-
sume will not be adopted by practitioners.   Some ancient  authors
had  already however seemed to  have felt the necessity of such a
process, for Heister recommends that we should make the puncture
into the bladder by means of a grooved  trochar, which could after-
wards serve as a director to the bistoury.
  II. Method of Franco.—Dionis and Toilet consider that the surgeon
might confine himself to the method adopted by Franco, that is to say,
to introduce two fingers into the rectum, in order to raise up  the cal-
culus towards  the  hypogastrium, so that we might cut down upon it
a little to one side of the linea alba.  They find this method easy and
simple, and more certain than  that mentioned by Rousset.   If the
stone were of such small volume, the symphysis of such inconsidera-
ble height, and the aggregate of the parts of so little thickness, as to
enable the fingers to push the foreign body in this manner to as far as
above the  pubes, this process would  possess real advantages, and
would deserve to be adopted.   Proby  used it, and it was by this pro-
cess  that Lassus, M. De Guise, and some others were enabled to re-
move from the bladder calculi, which they had found it impossible to
extract through the perineum.  It is nothing  more in  fact, than the
little operation of the  ancients transferred to  hypogastric lithotomy,
with this difference, that above the pubes there would be less incon-
venience in cutting down upon the  stone, than  if we had to extract
it through the lower strait.  As to the manipulation of the operation,
it is altogether useless to give it in detail.  Franco merely says, that his
patient was operated upon " on the mons veneris, a little to one side,
and over the stone, while he raised up this last with his fingers, which
were in  the fundament,  and keeping it  moreover under his con-
trol  by means of the  hands of an  assistant,  which made  compres-
sion on the lower belly."  It is well to remark,  en passant, that Franco
had not previously incised the perineum  in the infant, two  years of
age,  mentioned by him, as has been repeated in a great number of
works, and that it was only after having found that all his efforts to
depress  the stone  were  useless, that  he decided  upon " cutting the
said  infant above the ossa pubis."
  III. Method of F. Come.—Hypogastric lithotomy appears  to have
undergone in  its successive modifications, almost all the varieties of
the perineal operation.  In the same way, as  for a long time it was
the practice to make the stone descend towards the neck of the blad-
der,  in order to incise the parts over it, so also has it been with the
high operation.  In this latter, however, they  soon adopted the  pre-
caution of distending the organ by means of  injections.  In the last
century Bamber, Cheselden and Foubert suggested the same course
for the purpose of avoiding the employment of the conducting sound.
Finally, if it was thought that this last instrument was indispensable
in all the processes of the low operation, so also have a great number
of authors recommended its employment in the supra-pubic method.
Rousset refers to it without being an advocate of it.  It appears that
at his time it was a hollow and grooved sound, which could be used
at the same time as a catheter for making the injections, should they
be deemed advisable, and also " as a sound for directing the  incision 
LITHOTOMY.
625
 in the manner of the Marianists;"  that is to say undoubtedly, that
 we could  turn either its groove or its  convexity  forward, which,
 however, would not be an easy matter.   At a subsequent period the
 Bound was recommended. fey P.etre, Heister, &c. ;  by some for the
 purpose of distending and raising up the bladder, while several others
 had a groove running along  its concavity, for the purpose of direct-
 ing the point of the bistoury.  But the instrument which has atti-acted
 most  attention in this respect is  the one contrived by F. Come, and
 which gave this ecclesiastic so great a predilection for the high ope-
 ration, that from the year 1758 to 1779 he had already made use of
 it in 100 cases. This instrument is known under the name of the
 sonde-a-dard.  It is introduced  in  such  manner that its  extremity
 may glide from below upwards, behind the symphysis, and reach above
 the pubes  while passing against  the  anterior region  of the bladder.
 The walls of the belly having been incised, the  point of the  instru-
 ment  is  made to project slightly into the  wound, by making a slight
 pressure on its plate outside, as if for the purpose of pushing it  back
 and depressing it.  The  surgeon  seizes  it through the walls of the
 bladder by its  projecting extremity, with the thumb and forefinger of
 his left hand,  or  he applies in  front of it  a sort of canula which
 flares open like a funnel.  The dart  (le dar.d) being  pushed  from
 below upwards, perforates the bladder  in escaping  from its sheath,
 in order to  come to the outside.  Whether  the extremity  of this
 dart shall have been unscrewed, in order that we may leave its stem
 only in the wound, or whether it consists only of a single piece, the
 bistoury is to be guided on the groove of its concavity, then from above
 downwards, and from before backwards, in order to  incise the walls
 of the bladder to such extent as may be deemed advisable.  Nothing
 more remains to do than to withdraw it into its sheath, the projecting
 point  of which had not left the bladder, and which itself is to be im-
 mediately removed.   The other  stages of the operation are the same
 as in the process of Morand.
  a. We perceive that the sonde-a-dard enables us  to  dispense en-
 tirely with  injections, that it stretches the parts to a proper extent, and
 that its grooved stem becomes an excellent conductor when we wish
 to enlarge  the opening into the bladder with  the bistoury.  With the
 view  of giving it still greater efficacy, Scarpa and M. Belmas have
 made some modifications in it.  Thus, it has been frequently objected
 to it, that it may wholly escape through  the puncture  made by the
 dart,  and  allow  the bladder to retract before it  was possible to
open into it with the bistoury.
  The surgeon of  Padua remedies this inconvenience in the follow-
ing manner.  His  catheter is not grooved except at  some lines  dis-
tance   from the extremity,  which  latter consists of a beak  dila-
 ted into  an olive  shape.  This groove  is moreover very wide  and
deeply excavated, in order  to leave on  each side of the stilette a
furrow of sufficient depth to enable the point  of a  bistoury to glide
upon it.  The perforating stilette, intended to pass through it, sepa-
rates  from it by degrees, and goes beyond  it  to the distance of
two or three lines in advance of its extremity, which latter in  this
manner is retained in the bladder, and cannot escape  from it  to  fol-
low the stilette.  Scarpa also alleges that the nail can always distin-
  vol.  m.                     79 
626
NEW ELEMENTS  OF OPERATIVE SURGERY.
 guish its borders through the walls of the bladder, and that the bis-
 toury may be conducted upon  it without  any danger  by passing on
 one side of the stilette.   The  sound  of M.  Belmas,  however, is so
 complicated that it will not be adopted at least in its  essential points.
 Other  conducting  instruments have  also been  proposed at various
 epochs.  Cleland, for example, proposed in the last century a sound,
 which after being introduced  into the  bladder, opens like a forceps
 and enables us in this manner to make a greater or  less degree of
 tension upon  the walls  of the  organ.  Kulm, L'Heritier, &c, have
 produced nothing better, and the very complicated apparatus  which
 M. Rouget wished to bring in  repute some years  since, and the ob-
ject of which was to enable  us with one movement to make an im-
 mediate perforation of the entire thickness of the walls  of the belly
 and bladder, also does not deserve to be revived.   M. Leroy d'Etiolles,
 (Cystotomie Epipubienne, Paris, 1837,) has contrived aponeurotomes,
 (Oper. Cit., fig. 1, 2, 3, 4, 5,  and p. 9. 10,11,) suspensory cystotomes,
 (Ibid., pp. 18, 19, fig. 7, 8, 9, 10, 11,  12, 13,) dilating  hooks, (Ibid.,
 pp. 22, 23, fig. 14, 15,) &c, the use of which also in  my opinion do
not appear to promise any great advantage.  The only question to
be determined would be, if the conducting instrument was exclusively
designed to stretch the  organ and  to prevent its retracting, or if it
was at the same time intended  to perforate  this  cavity from within
outwards, in  order to serve as  a  more certain guide for the bistoury,
destined  to complete the incision.   In the first  case, an ordinary
catheter  would sufficiently carry out the views of the surgeon ; in the
second, the sonde-a-dard, whether simple, or such as it has been mod-
ified by Scarpa, leaves certainly nothing to be desired.
  b.  Button-hole Incision.—The employment  of conductors has not
been the only change made  in  hypogastric lithotomy.  Various sur-
geons have proposed to make an opening underneath the pubes.  This
opening, which had already been performed by the Dutch surgeon,
 Sermes, who  on that account was even pursued  by the tribunals and
defamed  by envy, sometimes consisted only of a simple puncture, and
at others resembled in some respects the lateralized operation.   Ser-
mes  recommends that we should use it for conducting  the suspen-
sory  sound.   Palluci made a puncture with  the  trochar at the
same point, and left a canula remaining in the wound.   Deschamps
recommends  that the puncture  should be made  at  the  rectum, in
order that it may give passage to the instrument which has been pro-
vided with its arrow, (fleche.)   It is, however, to F.  Come that the
supplementary incision  chiefly  owes the reputation which it has en-
joyed.  This  lithotomist, who commenced his operation with it, inci-
sed the membranous, and  also  in part the prostatic  portion of the
urethra upon  a grooved sound,  and then made use of the wound to
introduce through it the sonde-a-dard into the  bladder.  After the
operation, a large short canula, left to remain in  the solution of con-
 tinuity, served by giving egress to the urine, to  prevent  its effusion
towards the hypogastrium.  The arguments presented, and the suc-
cesses obtained by  F. Come, for a moment led to deception on the
importance to be attached to an  incision of this kind ; but some persons
soon asked themselves  the question, if this process could in reality
 possess any advantages for the high operation, or whether it would 
LITHOTOMY.
627
not, on the contrary, complicate it in a dangerous manner.   It Was
easy to perceive—1st, that the wound of the perineum did not pre^ ent
the urine from getting into the hypogastric wound ; 2d, that it is not
required for the introduction of the sonde-a-dard; and  3d, that it
must add almost all  the dangers of the lower  operation to  those of
the upper.   Thus, Scarpa  in 1808,  and  Dupuytren in 1812, endea-.
vored to reject the modifications of  F. Come, by demonstrating that
the instrument contrived by this practitioner, could,  if introduced
into the bladder through the urethra, be made  to  manipulate full as
well as  through  the perineum.  Nevertheless,  the  process of  the
Feuillant ecclesiastic continued to be followed, until Home, abandon-
ing this method, performed in two  instances, in 1819  and 1820, the
hypogastric operation according to trie principles laid down in  the
dissertation of Dupuytren.  Some years  after M. Souberbielle him-
self renounced the precept of his ancestor, and which precept he had
no longer followed since the year 1825;  so that at the present day
the question is definitively adjudged, and no longer requires discus-
sion.
  B.  Operative  Process.—The  processes which  have just been
passed in review, notwithstanding  they  are different, present rules
which they have in common. These rules relate either to  the posi-
tion of the patient, to the incision of the tissues, or to the means of
passing off the urine and dressing the wound after the operation.
  I.  The position of the patient ought to be that which is recom-
mended for the operation of hernia, with this difference only, that it
would be advisable to have the pelvis slightly elevated.  If  the legs
were  allowed to  hang from  the  table or bed, they  would increase
the tension of the abdominal  muscles, and expose, in this manner, to
a variety of inconveniences.  In folding  them upon  the thighs as in
the perineal operation, they would interfere with  most of the move-
ments of the surgeon.  If necessary, the operation might be made
on an ordinary bed; but  a narrow table of an appropriate heigh*
renders the position of all  parties infinitely more commodious.
  II. Injection of the  bladder.—When we propose  to distend  the
bladder by means of liquids,  we must begin by introducing  an ordi-
nary catheter through the urethra.  The syphon of a syringe filled with
tepid water is then attached to  the pavilion of the  catheter.  The
injection is to be thrown up gently, and in such  manner as  to make
as much  of it  penetrate into  the bladder as the patient can  support
without experiencing any pain.  No one at the present day would
think of using the urethra of an ox, the trachea of a turkey, or a lea-
ther catheter, as is recommended by Douglas, Cheselden, Middleton,
and Solingen, as a medium of communication between the catheter
and syringe, in order thus to prevent all  kind of concussion.  As
soon as the injection is terminated  an assistant is directed  to com-
press  the urethra, for the purpose of preventing the liquid from
making  its escape  before it is time  for it to do so.  It is true that
many persons do not need  this precaution, but as it is not the same
with others, prudence would  not allow of our neglecting it.   As to
the compressor of Nuck, Winslow, &c, the fingers may be perfectly
substituted for them.
  III. Incision of the  external parts.—The surgeon being placed 
628
NEW ELEMENTS  OF OPERATIVE SURGERY.
upon the right rather than between  the  legs of the patient, as M.
Belmas  recommends,  proceeds to lay  open the hypogastric wall.
It would be absurd to discuss the advantage of  this or that lorm ot
bistoury for this stage of the operation ; whether it be a razor, the
convex  or straight bistoury, or  the small  ordinary knife, is a  matter
of little  importance, provided it has a good cutting edge.  It is to be
held in the first position, that is to say, in the manner of a table-kniie,
and after  having stretched the parts with the left hand, we divide
from above downwards, to the  extent of three or  four inches, first
the integuments, then the cellulo-adipose tissue, and  thus in this man-
ner come down upon the aponeurosis.  It is better, whatever Zang
may say to the contrary, to  have this incision  a  little  too long ra-
ther than  too short, and there will be an advantage, notwithstand-
ing the  contrary opinion of Winslow, in prolonging it upon the front
part of  the  symphysis to a half an inch below the superior  border
of the pubes.  The incision of the aponeurosis is not  made  in  the
same way by all surgeons.   Though  there may be  some who make
it with the same  instrument which they have used up to this point of
the operation, there  are  others, and Scarpa  is of this number, who
recommend, that after having incised into it very low down, we should
glide underneath it a grooved sound which is  made to pass be-
tween  the  peritoneum  and  the  wall of the abdomen, from below
upwards, in order that we may  conduct upon it a bistoury in the
same direction, to divide through the whole thickness  of the fascia.
F. Come employs for this purpose an  instrument which terminates in
& triangular point at one extremity, and in a handle cut into facettes
(taille a-pans) at the other, and which contains a cutting blade, hav-
ing a plate at its free extremity, and opens from the  heel towards
the point,  and consequently in  a direction which is the reverse of
that of  the  concealed lithotome.  This trochar is  plunged  in  from
before backwards, and  from above downwards, until it arrives be-
tween the symphysis and the front part of the bladder.  The sur-
geon  with his right hand fixes its  stem against the  bones ; seizes
its  plate with the thumb  and forefinger of his left hand, separates
this plate from the  handle from  below upwards, and  divides in the
same direction  the linea  alba  as well  as  the entire  thickness of
the  other  tissues  which  lie beneath  its cutting   edge.   Having
withdrawn the  trochar, F. Come  introduces in its  place  a  bistoury
terminated by an olive point, with a cutting edge upon its concavity,
and fixed upon its handle ;  then incises from below upwards with
this second instrument held in his right hand and protected  or  sup-
ported  by the first fingers of his left  hand, all the layers which may
have at first escaped him, taking  care to  make  its  button  point
pass  between  the  bladder  or between  the  peritoneum itself and
the deep-seated surface of the aponeuroses.   At first  sight, the pro-
 cess of F. Come would appear to be  more dangerous than any other.
 It  is  calculated to  cause  alarm  to see the edge of his trochar bis-
 toury acting in this manner from below upwards, and from before
 backwards.  As it cuts however by pressing,  rather than by a saw-
 like movement; and as at  the greatest degree  possible at which it
 may be opened, its blade  represents  a line strongly oblique from
 the integuments towards the bladder, it rarely happens that the peri- 
LITHOTOMY.
629
toneum is actually wounded.   The only  reasonable  objection that
may be  made to it, is that it is not indispensable,  and  that  any
person practised  in the performance of  the great operations will
manipulate with  full  as much security with an ordinary bistoury.
Under this point of view the improvement which M.  Belmas has
made  upon it, and which consists in making it concave  on the
back,  and  convex on the cutting  edge, does not  appear  to me to
possess any great advantage.
  As to the probe-pointed  bistoury of F. Come, I have, while making
my pupils manipulate on the dead body, a thousand times perhaps
replaced it by the ordinary probe-pointed bistoury, and have never
felt the necessity  of employing one of a particular kind.  Almost all
surgeons of the present day recommend that the incision should be
made directly upon the linea alba ; M. Baudens, however,  recurring
to the  advice of certain authors, has endeavored to prove  that it is
better  to go outside of this fibrous  line, alleging that if the  wound is.
placed between it and the inner border of the rectus muscle, we ex-
perience less difficulty in enlarging it, and in separating its lips to
come down upon the front part of the bladder.  This, however, is one
of those recommendations which may be followed or omitted without
any inconvenience.  The  important point is to penetrate between the
two muscles, and  not through their fibres.  Whether the linea alba
after that remains intact on one of its sides, or whether it has in real-
ity been  separated into two equal portions, is a matter that we need
not trouble ourselves about.   I will remark, that the reason why we
ought not to make the  bistoury pass through the muscular fibres, is not
so much  owing to the danger of incising them, as it is in consequence
of the greater thickness  that we should have to cut through before
arriving at the sub-peritoneal  cellular tissue, and because the serous
membrane is found more closely applied to the deep wall  of the hypo-
gastrium, upon the outside of the median line, than it is upon the cen-
tre itself.   The ordinary straight  bistoury, held like a knife or pent
is full as  good as any other, to incise from  above downwards, and in
succession, the skin, adipose layer, and aponeurosis.  Having arrived
to this  aponeurosis, the surgeon should proceed with caution and di-
vide it layer by layer, taking care to press with much more force while
approaching the pubis than at  the upper half of the  wound.  As we
unavoidably come down upon  the  pubeo-yesieal triangle, on the me-
dian line, and inasmuch as with a  little attention we may always re-
cognize that we have  reached this  point, the  peritoneum does not in
reality run any risk during this  part of the < operation.   Upon the
supposition that more  intimate adhesions above should  prevent our
opening into the aponeurosis on this side  to a  sufficient depth, the
probe-pointed  bistoury should then be substituted for  the  straight
one.  Its extremity should be applied to the  triangle above  men-
tioned, immediately above the symphysis, against which the operator
might for greater security hold  its back supported with his right hand,
while with the forefinger and thumb of his left hand, he would grasp
its blade  at its sides, to draw it from  below upwards, and  to oblige
its button to glide on the anterior surface of the bladder,  or the lower
portion of the peritoneum itself, between  those parts and the deep-
seated  side of the linea alba,  to the extent of about two inches.   It is 
630
NEW ELEMENTS  OF OPERATIVE SURGERY.
true that the opening into the bladder is made with less danger below
than above; but in the first case, we have to direct the cutting  edge
of the bistoury towards, the umbilicus, which would expose to consid-
erable risk of wounding the peritoneum ; while in the  second case, if
this membrane has not been wounded at first, we are  almost, sure of
avoiding it afterwards.  It is unnecessary to seek for the origin of the
urachus, or the middle  point which separates this cord from the pubes,
as Middleton and some others have suggested.   The  important mat-
ter is to come down on the anterior wall of the organ, on some point
which is not covered by the peritoneum, and this constitues the whole
matter.   This puncture is made with a straight bistoury, guided upon
the nail  of the left forefinger, and inclined from  above downwards,
full as well as with the little concave knife of Cheselden or Rousset.
In withdrawing the instrument, we should take  care  to enlarge the
wound rapidly, in order to enable us to immediately introduce a sus-
pensory instrument into the bladder.  The forefinger turned above,
in the manner of a hook, performs  its  office at first.   If,  after  that,
the walls of the belly should appear to  be too thick, and seem to pre-
sent a difficulty in reaching the bladder, we might follow the  recom-
mendation of Zang, and separate the  lips of the wound apart  with
two small  blunt hooks.  The finger crooked above, again serves to
direct the  bistoury, which is to be had recourse  to for enlarging the
wound in the bladder, and  prolonging it towards the neck, to the ex-
tent of an inch or more, according to  the  presumed  volume of the
calculus.  In ordinary cases the same bistoury, that  is to  say, the
straight  bistoury, will also answer for this purpose, and is better even
than  the probe-pointed bistoury in this respect, that its point more
thoroughly divides the tissues when it is withdrawn.  If, however,
on account of the embonpoint of the patient, its employment should be
attended with any difficulty, the concave bistoury of Pott might  be
advantageously substituted for  it, and  would render  wholly useless
the concave bistoury  proposed  by the  ancients.   As to the  scissors
that are curved on their border, I know of no circumstance that can
render their employment necessary.  If the finger should  appear to
take  up  too much room during the time of introducing the tenacula or
of extracting the  calculus, or if it should be apprehended  that it
might be wounded during  these  last manipulations, an instance  of
which was seen by Deschamps, we  ought, whether  it be the finger
of the operator or that of  an assistant, to replace it by a  special  in-
strument for this purpose.   The blunt  hook of F. Come would  then
answer perfectly well.  The species of gorget, however, with a han-
dle, and bent almost into a right angle near its extremity, like the one
constructed by M. Belmas, would be evidently preferable    In fact
this suspensory  instrument, the gutter  on  which should face down-
wards, would keep the lips of  the wound  open, and  form an excel-
lent conductor, without in any manner moreover incommoding either
the artificial opening or the inner surface of the bladder.   After this
nothing  more remains than to withdraw the calculus
  IV. The use of the director.—When we make  use of a director, it
is better to adjust it before opening into the hypogastrium than after-
wards ;  in the first place, because its point m'ay in some cases serve
as a guide above the pubes; and in  the second place, because its
in- 
LITHOTOMY.
631
troduction afterwards would give greater uneasiness to tlie patient.
We will suppose that the  sonde-a-dard is the one  to be employed.
The surgeon introduces it in the manner of an ordinary sound, glides
its  concavity behind the symphysis, and in this manner conducts its
point to above the upper strait, and  opposite to  the linea alba.   An
assistant is directed to keep it in this position, while the  operator
proceeds to divide the integuments and the aponeurosis.  The blad-
der being now laid bare, the surgeon again takes the sonde-a-dard,
withdraws it slightly in order to bring back its point again from be-
low upwards, while  grazing  gently against the  pubes and in such
manner that the peritoneum may not form a duplicature in front of
that part of the wall  of the bladder which the  point of the instru-
ment is  intended to  make  protrude  through the wound.  The  left
forefinger  introduced  into the  bottom of the  wound enables us to
appreciate these movements, and  points out the height to which it
has arrived, and the degree  of protrusion it makes.  After having
adjusted it in a proper manner it is again  consigned to the assistant.
The surgeon, who immediately  pinches the salient point by the sides,
then  directs the  assistant  to push upon the dart, which he  causes
to  emerge to the  distance of one or more inches, and the point of
which he  unscrews if he  apprehends any embarrassment from it.
Without changing the position  of his left  hand,  he takes in his right
hand a bistoury which, according to Scarpa, should be convex, and
on  the contrary concave, according  to M. Belmas, but which may
be  straight or the ordinary  bistoury, and nevertheless  have the same
advantages ; places  its point, while  holding it  as a  pen, upon the
groove of the sound;  penetrates into the  bladder and divides it on
the median line from above downwards and from before backwards,
nearly as far as to its neck or to the prostate;  then  withdraws the
tlart into its  sheath  and immediately introduces the  left forefinger
into the  bladder.  The  assistant  now removes the  sound, and if
the surgeon considers  it to be necessary to make use  of an artificial
suspensory, he  attends for  the  moment  to the adjusting of the one
that he selects ; takes  the hook or the beak gorget in  his right hand,
supposing that this is the one he  prefers; presents it at the wound
into the bladder in the direction which is  most suitable; raises it up
after it has entered into this organ; glides it  in the place of the
forefinger,  which  he replaces in the lower angle of the wound, and
immediately leaves the instrument in the charge of an  assistant.  His
two hands being now free,  he explores without any difficulty the in-
terior of the bladder, and ascertains  the volume  as well as the posi-
tion of the calculus, the extraction of which is  the only thing that
remains to be  done to  complete the  operation.  This  extraction,
which may frequently be effected by means of the forefinger curved
in the manner of a hook, or by  the forefinger and the thumb, or by
the forefinger aided by a scoop, requires in other cases the assistance
of tenacula, which are generally managed with  more  facility in this
operation than in infra-pubic  lithotomy.   The precautions  to be
attended to in using  them,  moreover, are  precisely the same.  Only
that we should  observe sfnl more caution than ever to avoid sepa-
rating the  bladder from the pubes  and  abdominal wall,  and that
we may  not in any manner cause a laceration of the loose cellular 
632
NEW ELEMENTS  OF OPERATIVE SURGERY.
tissue placed between these different organs.  Dzondi, (Bull, de Fir.,
t  XXII.,  p.  424,)  with a view to avoid making any devious track,
drew through the  wound  by means  of the sound in the bladder, a
concave plate, which enabled him to extract the stone.  M. Knmer,
(Journ. de Graefe  et Walther, vol. X.,  p. 578,)  being unable to ex-
tract a calculus  through  the incision at the perineum, had recourse
to the hypogastric  operation to extract a stone twenty-three ounces
in weight, and thus cured  his patient.   Calculi respectively of nine
and a half ounces,  twenty-five and a half ounces, and  three  pounds
three ounces, are said to  have been extracted in  the same manner,
(Pechlin and Verduc, Theses de Holler, t. II., Fr. transl.)   Noel thus
extracted  one of more than four inches in diameter,  which was shown
to me by M. Loze.   M. Mandt, (Kleinert's Repert., Janvier, 1836, p.
51,)  after having extracted  three calculi through the perineum, was
obliged to lay open the hypogastrium  to remove  a fourth.  In  the
case of M.  Leonardon, the stone, which  completely  filled  up  the
bladder, left behind an incrustation which had to be scraped down
and  removed with  a scoop.   M. Voisin, (Gaz. Med., 1836, p. 373,)
who had  incised the tissues nearly transversely, was not enabled to
remove any more than the body of the  stone, the head of which re-
mained strangulated  in the prostatic portion of the urethra.  In an-
other case, M. Voisin, (Gaz. Mid., 1839,  p. 90,)  after having  cut
through all the tissues of the hypogastric region, and also the walls
of the bladder, by  means  of a simple bistoury, found that the stone
was expelled  in some measure of its own accord, so that his patient
was  promptly restored.  As  the  largest sized calculi may  be  ex-
tracted at the hypogastrium, and  as in this region a small  wound
could scarcely be  attended with less danger  than a  large one, we
cannot comprehend  why M. Dudon  should  have  recommended
that  we ought to  make use  of puncture, by paeans of  an enor-*
mous sized canula, in order to  dissolve the stone in  its  place, nor
how puncture with dilatation and  lithotrity through the wound of
the hypogastrium,  and which is so much eulogized by M.  Franc,
(Nouv. Meth., &c, 1836,)  could offer the  slightest advantage over
pure and  simple lithotomy.
  V. Dressing.—Supra-pubic cystotomy, different from other kinds
of lithotomy, has occupied much of the attention of operators in re-
lation to the dressing which is best adapted to it.
  a. The  suture of the wound was recommended at the time of
Rousset, and  has frequently been made use of since.  It was hoped
by this means to prevent the urine from passing through the  hypo-
gastrium,  and of becoming infiltrated outside of the bladder.  This
suture, which has  been more frequently advised than used, is far
from having  been  understood in the same manner by the different
authors who have ventured to recommend it.   Solingen, one of its
warmest  partisans, does not express himself with sufficient clear-
ness to enable us to understand positively whether he confined him-
self to sewing up  the  skin, or  included at the same time the en-
tire  thickness of  the lips  of the  wound.  Others have expressed
themselves more categorically on this  subject.  Douglas, for  exam-
ple, considers that  the suture of the integuments wou?d be  sufficient.
Rossi, on  the contrary, alleges that we should  especially  endeavor 
LITHOTOMY.
633
 to  suture  the vesical wall itself, while Gehler ma ntains  that the
 whole should be  embraced in the same ligature.   Monro,  (J. Bell,
 Traitii des Plaies, translation of Estor, p. 388,) who recommends that
 we should operate upon the patient under water, in order  to avoid
 the action of  the  air on the bladder, also prescribes the suture with
 the same intention.  The cases  related  up to the  present  time,
 whether in favor or against the suture, scarcely  prove any  thing.
 Heister, it is  true, says that  Praebisch, who had used it on  a pa-
 tient,  soon saw such alarming symptoms  supervene,  that he was
 obliged to cut the points and to  withdraw  the threads.  But how
 had the suture  been applied ? what  tissues had been perforated by
 it ?  and  to what degree had the coaptation been effected ?   We
 ate left wholly in darkness  on the subject.   M. Pinel Grandchamp
 (Arch. Gen. de Med., t.  IX., p. 612,)  had  recourse, in 1825, to some
 investigations on  this subject.  After having opened the bladder in
 a certain number of dogs,  he closed it up with the  suture, and the
 operation in these animals, it is  said,  succeeded sufficiently  well.
 Since that  period M. Cazenave  (Bull. Med. de Bordeaux,  1833,
 p. 82,) and M. Amussat  have pronounced  in its favor, and related
 several cases of successful results.   Nevertheless, it is a resource
 against which both  numerous and powerful objections may be ad-
 duced.  In the  first  place,  it is not  probable that any body here-
 after will have recourse  to the suture of the integuments exclusively,
 nor to that of the aponeurosis or muscles.   It would have the effect
 in fact, to close up the passage to the urine, without preventing its
 escape from the  bladder; the result  would  be to force this fluid to
 effuse itself into the cellular tissue of the pelvis.  As to the suture
 of the wound  into the bladder, it is far  from being  always  an easy
 matter.  Could the  urinary bladder have remained  distended up to
 the end of the operation, if the division of its anterior wall did not
 extend below the upper  border of the symphysis, and were the hy-
 pogastrium always found thin, we might, as I consider, hope to derive
 an actual  advantage from it.   But should the incision have been pro-
 longed to ever so litte extent towards the prostate,  how can we be
 sure that we  shall not  leave any  void between its lips, at its lowest
 portion ?  Afterwards, is it  not to be apprehended  that the points
 of the suture  themselves may, by becoming enlarged,  constitute so
 many  passages  for  the  urine ?  Ought we  not also to consider as
 something  the pain which their  presence will occasion,  and  the pro-
 tracted length which they give to the operation ?  The  suture then
 could  only possess some  advantage in those cases in  which it would
 be actually possible to unite the entire  extent of the wound of the
 bladder in the  most  perfectly accurate manner ; also, it would be
necessary that the glover's suture, which is the only one which could
 be proposed with any apparent degree of reason, could  be applied with-
out producing  too  much laceration, and  too much traction upon the
surrounding cellular tissue.   I conclude in fine, that the suture, under
whatever  fornl it  may be offered, ought to be  rejected in hypogas-
tric lithotomy.
  b.  The indication, however, which  it  was  proposed to carry out
by means  of the suture, is one of the highest importance; hence it
has  never ceased to  be an object of enquiry,   After  having devised
  vol. in.                     80 
634
NEW ELEMENTS OF OPERATIVE SURGERY.
 a great number of modes,  it has been supposed  that a canula left
 to remain in the wound would  be certain to conduct the urine ex-
 ternally.   Solingen is one of the first to whom this idea  suggested
 itself.   It is not, however, very certain that the leather sound which
 he mentions was  not  introduced through  the  urethra, rather  than
 through the hypogastrium ; but Heuermann, a German surgeon, leaves
 no doubt upon the subject, for Sprengel says in express language, that
 he warmly eulogized the utility of a canula  inserted into the incision
 after the operation.  An operation performed in the month of Decem-
 ber, 1818, at Dublin, by M. Kirby, and published in 1819, shows that
 this  surgeon had  some  confidence in the  practice of Heuermann.
 We perceive in fact, that after having terminated the high operation,
 he left  a tube in the  wound, in the same manner  as M.  Cazenave
 (Bull.  Med. de  Bordeaux, 1833, p. 82,) states that he did also, on
 the 17th of August, 1827.
   In France M. Amussat, who supposed himself to have been the
 first that made  this suggestion, came out with great zeal in favor
 of it.  The hopes  that some persons had indulged  in, in respect,to
 this  process, have  unfortunately not been realized.  M. Kirby per-
 ceived, at the expiration of four days, that the urine passed  between
 his canula and  the lips of the wound.  Some operations  performed
 by M. Amussat himself, have shown  that the same thing also had
 happened to him.   The fact is related of a patient at the Hospital
 St. Louis, and  in whom the conducting tube did  not prevent the
 formation of urinous  abscesses, if in  fact it was not the cause of
 them.   It is a law of the organism, that when a foreign body is  shut
 up  and closely embraced  within  the  lips of a  wound,  it  soon
 enlarges its position and enables the fluid to  glide over its external
 surface.  Consequently, a canula could not  prevent urinary infiltra-
 tion ;  and as its presence could  not  be unattended with inconve-
 nience, it in reality deserves  the oblivion into which it has fallen.
  c.  Surgeons have been so  reluctant to dismiss this suggestion, that
 they have  looked  for some  other mode by which they might be
 enabled to draw off the urine externally, in  proportion as it entered
 by the  ureters.   It is in this  manner that M. Segalas has proposed
 to insert a meche of cotton in a gum-elastic  catheter, and leave one
 extremity of this meche in the interior of the  bladder and  the other
 hanging outside, in  order to serve in the manner of a filter, forgetting
 without doubt  that  if the efficacy of this means were admitted, it
 must  necessarily produce  precisely  the  same  effect when  it  is
 placed in the  wound of the hypogastrium.  M.  Souberbielle  has
 recommended the use of an aspirating syphon, composed of a large
 flexible catheter placed in the urethra, and  a long  gum-elastic tube
 which  plunges  in a vessel placed below the plane  upon which the
 patient reposes   It was  for the purpose of carrying out the same
indication that M. Heurteloup contrived his  uretro-cystic tafre, which
 combined ,n some respects the apparatus of M. Souberbielle and  that
of M. Amussat,  inasmuch as it consists of a hollow tube which issues
through the wound, and of another similar tube which occupies the
urethra, so that  the urine would pass mto the lateral openings which
it meets with  near the neck of the Bladder, and  must necessarily
escape by one extremity or the other.   But  experience has not yet 
LITHOTOMY.
635
pronounced in favor of any of these  contrivances; and when we
reflect upon the annoyance they occasion to the urethra, bladder and
wound;  and when we  consider that in the horizontal  position in
which the  patient is  placed after the operation, the line of the arti-
ficial  opening is  sometimes less elevated than that of the  urethra
opposite  to  the suspensory ligament of the penis, it is  exceedingly
difficult to understand what advantages  their inventors could hope
to derive from them.
   d. A circumstance which  does  not  appear to have  sufficiently
attracted  attention, is the cause of that  almost invincible tendency
which the urine has to pass above the pubes.  At  first sight it would
seem  that in this  movement it ascends against its  own law of gravi-
tation.  In  examining it attentively we soon find that this is by nc
means the case.  It rarely happens, in fact, in the hypogastric  ope-
ration that the incision into the bladder does not descend as far down
nearly as to the prostate, or at least to the middle of the height of the
symphysis pubis.   This being admitted,  it is easy to convince our-
selves that the urethra, when  it comes out  from under the  pubic
arcade, is  elevated at  least  to as great a height, even when the
patient is almost in a vertical position, and that in  the horizontal posi-
tion the  urine has certainly a longer route to make to arrive at  this
point  than to reach the lower angle of the wound.   It would be time
lost therefore  to attempt the use of such means.
   e. The majority of practitioners have confined themselves to the
use of meches, either of linen or cotton, and one  extremity of which
is introduced  into  the bladder, that  it may perform the office of a
filter.  Tents  of  lint  and the dried  roots of plants would  be more
injurious than  useful.  It is not even certain that  the simple ravelled
meche of F. Come in  reality possesses any advantages ; it should not
at least, if we should have recourse  to  it, be besmeared with oil or
any kind of unctuous matter.  As the  blood and purulent matters
with which it  soon becomes impregnated almost immediately destroy
its permeability, there is scarcely, in fact, any benefit to be expected
from  it.   The only  real  want the operator feels is,  that of pre-
venting the parts, by their too rapid  agglutination in the direction
of the wound, from interposing an  obstacle to the passage of the
fluids which come  from the  direction of the bladder.   Should we,
during the first twenty-four hours,  leave nothing between the lips of
the wound,  we might perhaps in this respect  have some serious con-
sequences  to  apprehend ; but at  a subsequent  period, when the
reuniting process  has  developed itself, the permeability of the tissues
is so  much diminished  that we may leave to the  care of the system
everything  that relates to the cicatrization  and  the escape of the
urine.
  /. It is not  necessary for the patient, after the high operation, to
remain  so  long  a time  in  the  same  position,  as  after  perineal
lithotomy.   He may  turn upon one side or the other, or sit up, and
no one at the present  day would recommend that  he should rest con-
stantly on his  belly, as somebody advised in the last century.  I will
add that after  the first symptoms have passed over, and that at the
expiration of  from five  to six or  eight  days, should  no  accidents'
or fever have supervened, the patient  may  get  up and soon after 
636
NEW ELEMENTS OF OPERATIVE  SURGERY.
walk without any1 danger, but on the contrary with advantage, inas«
much  as  the vertical  or  seated  position unquestionably favors the
passage of the urine through its natural route.
  C. Accidents.—I.  Hemorrhage, to  prevent  which  so  many pre-
cautions  were adopted in perineal lithotomy, and against which the
high operation was apparently calculated to protect us, has never-
theless been noticed after  this  last in a number of instances.  Pye
makes  known a remarkable case, and  another is found in the obser-
vations of Thornill, quoted by Middleton, then  again  a third in the
work of  M. Belmas; while I myself know that one of the  patients
operated upon by M. Souberbielle came near  being  a victim to it.
M.  Cazenave (Bull. Mid. de  Bordeaux, 1833, p. 82,) was even com-
pelled  to perform hypogastric lithotomy, in order to withdraw from
the bladder clots of blood which  had  been collected there in conse-
quence of a  simple  puncture.   M. Tonnelle informed me  (March,
1839,)  that in one of his patients, who  died in this manner, it  was im-
possible to discover the lesion of any vessel, and that the blood evi-
dently issued by exhalation from the interior of the bladder.  Up to
the present time surgeons have not been enabled to specify the vessel
which gives rise to this  sanguineous exudation.   Some have supposed
that it depended upon sub-cutaneous veins or arteries that were more
largely developed  than usual; while others  have imputed it  to arte-
rial anomalies in the substance of the linea alba, or in the fascia pro-
pria.  Some also have conjectured sanguineous exhalations from the
internal surface of the  bladder.   But  in  all these opinions  there is
scarcely  anything  at bottom but bare supposition, having a greater
or less degree of  probability.  Anatomy, moreover, would  perhaps
furnish an explanation  to  this accident, if more attention had been
manifested in practice to  discover its seat.  It might, for example,
turn out  that the arteries, which  naturally mount up upon the sides
of the  bladder and cross each other above its neck, might constitute
a noose of sufficient size to  account for  this hemorrhage; it might
also be possible that the dorsal arteries of the penis, coming  directly
from the hypogastric and  passing upon the sides or above the pros-
tate, as in the  cases mentioned by  Burns, M. Senn, Shaw, &c,
might have been divided if the incision had been prolonged  very  far
down.   However  this may  be, this accident  is rare, and  surgery
possesses a number of  means of triumphing over it.   Should it hap-
pen during the operation itself, it might  be possible, as all the parts
that are divided are exposed to view, to discover the wounded artery,
to seize it with a sufficiently  long pair of forceps, and to twist or tie
it.   In the contrary case, that is to say when  the hemorrhage does
not take  place until after the dressing, we may  begin by  keeping the
pieces wet with cold water during the space of several hours should
not the loss of blood threaten to exhaust the patient; otherwise  we
should have to lay bare the  wound and  look for the vessel.  Upon
the supposition that we could not reach it  or discover its seat, tam-
pons saturated with Eau de Rabel, or with some hemostatic 'lotion
of any other description, should  be inserted into the bladder.   We
might  also introduce into  this organ a large sized roll of  lint, having
fastened to it a long double thread destined to receive between its two
heads  a  second tampon, upon which  they are  to be tied in front of 
LITHOTOMY.
637
  the wound, in such manner as to  make sufficient compression upon
  the tissues from behind forwards.  We ought also to have previously
  removed all the clots contained  in the bladder, and  even washed out
  this cavity with copious injections  of water.
     II.   Middleton alleges that the prostate may be wounded when we
  incise  too  deeply, which assertion is true; and moreover, that this
  wound may  frequently give, rise to a dangerous ulcer, which, in my
  opinion, appears to be entirely destitute of foundation.   He also
  speaks of injuries done to the symphysis pubis, and of the accidents
  which might result from them;  but at the present day nobody pays
  any attention to these lesions, which, in fact, scarcely deserve to  be
  mentioned.
     III.  Abscesses.—One of the accidents most to be dreaded is  the
  formation of abscesses around the periphery of the bladder.  Douglas,
  Cheselden, and almost all those authors  who have since  occupied
  themselves with  the subject of hypogastric lithotomy, have made
  mention of them.   There  are two descriptions  of  these and which
  we must endeavor not to confound.  One order arises from the infil-
  tration of a greater or less  quantity of urine between the bladder
  and the surrounding tissues ;  while the others are the pure and
  simple result of inflammation of the cellular tissue of the pelvis.   It
  is readily  conceived that  if the operation  has  been attended with
  numerous lacerations and extensive separations, the urine will readily
  effuse itself into the cellular tissue instead of escaping to the exterior,
  and everybody knows how dangerous are those inflammations that
  are caused by the urine.   Should there  have  been no decollement
  we rarely meet with  these infiltrations.  In fact, after a few hours,
  the lips of the wound have lost a considerable deal  of their porosity,
  and the  fluid passes over them without insinuating  itself, as it might
  have been apprehended  it would  do, into their  tissues by the force
  of gravitation or capillary attraction.   The passage  and infiltration
  of the  urine external  to the wound, does or does not take  place ac-
  cording as the bladder in retracting does or does not bring the lips
  of the  division  into contact.  This condition  appears to me to em-
  brace the whole secret of the dangers and successes of hypogastric
  lithotomy.  Unless the reaction should be very intense, and that the
  parts have become very red, and that  there is an  acute degree  of
  fever  present with a full and strong pulse, sanguineous evacuations
  either by leeches or the lancet, will be rarely found  of any great ad-
  vantage in such cases.  The urine that has penetrated by transuda-
  tion into the lamellar  tissue  constitutes a putrescent fluid.  If there
  be anything which can arrest its ravages, it would  be scarcely any
'  other than deep incisions, multiplied to a great extent and as speedily
  as possible, upon all the parts that have become infiltrated, and even
  upon those in the neighborhood.  Unfortunately the seat of the mis-
  chief cannot  always be reached by this remedy. Nevertheless, we
  should  make  these  incisions penetrate  in  every direction where we
  can do so without  its being attended with too much  danger. The
  wounds are afterwards to  be dressed, at least until the eliminatory
  inflammation  is developed,  by means of tincture of camphor, decoc-
  tion of bark, or some solution of chlorine.   Ordinary abscesses with-
  out urinous infiltration, are  of more rare occurrence, and are almost 
638
NEW ELEMEN19 OF OPERATIVE SURGERY.
always to  be imputed to the manner in which  the operation haa
been'performed.  When  the bladder has been opened by the sonde-a-
dard or by the bistoury, the forefinger introduced into the bottom of
the wound, so readily pushes  it backwards in place of entering into its
cavity, that it frequently happens that it completely detaches it from
behind the pubes, and Yorms there a large pouch which necessarily
becomes the source of a violent inflammation and abundant suppura-
tion.  There can  be no doubt that this result has taken place in most
of those cases in which the operators have alleged that the bladder
was found to have been partitioned into two cavities, one anterior in
which nothing was discoverable, and the other posterior, which con-
tained the calculus.   In these cases antiphlogistics are not suitable
unless  the  patient is sufficiently strong to support them,  or  unless
extravasation  of urine  be   not  complicated  with  an  accident,
which is in itself of so serious a character.   Moreover we must give
as free  egress to the fluids  as possible, and  not  have any fear of
multiplying  the incisions or  of increasing their extent in different
directions.
  IV. Lesion of the peritoneum.—The lesion unquestionably  which
has been most spoken of in hypogastric lithotomy,  is that of the peri-
toneum.  Almost  all authors  have looked upon it as one of the most
dangerous character, and some even consider it to be always fatal.
Without pretending to deny its gravity, I  nevertheless consider that
its dangers have  been singularly  exaggerated.  It is  certainly not
calculated in itself to create  much apprehension ; but much  rather
from its enabling the urine to extravasate into the cavity of the ab-
domen.   Now the operation  is no  sooner terminated than  the blad-
der falls down, retracts, and agglomerates behind the symphysis.
The wound in its walls, from that  time,  is no longer  placed  in re-
lation with that of the serous envelope.   Consequently  the urine
cannot in reality escape through that wound, and thus reach the ab-
dominal cavity.   What proves this  however better than arguments,
is the fact, that the peritoneum has been frequently wounded without
the slightest accident of a serious character resulting from it, and that
in patients who have died with this wound, causes sufficient to pro-
duce death have been found, which were  entirely  independent of it.
One of the patients operated upon by Douglas, had the peritoneum
laid open, but recovered notwithstanding.   One of those of Thornill
was equally fortunate.  It is  even said that in another who also got
well, the intestines had escaped through the wound in  such manner
that they had to  be reduced.  The same  accident happened to F.
Come and M. Souberbielle, without those surgeons  appearing to have
entertained much apprehension from it.  A  woman who was  opera-
ted upon at Tours, in 1828, by M. Crozat,  and who also had the peri-
toneum laid  open to a very considerable extent, was nevertheless
perfectly restored.  M.  Leonardon (Observ.  a VAcad., 22d March,
1837) has since published another  example,  which  is one of the most
remarkable.  It is said that Dupuytren was not so fortunate • but if
the account  given  of his operation  is correct, a  meche  must have
been introduced  into the interior of the  serous cavity  in place of
having gone into the bladder itself;  from  whence it follows that this
fact does not unreality demonstrate the dangers of a wound  of the 
LITHOTOMY.
639
peritoneum.   When it has taken place, we should, in my opinion,
aggravate the danger  by sewing its lips together, as recommended
by MacGill, or by applying a suture to the entire extent of the solu-
tion of continuity, or at least to its upper half, as is recommended by
Douglas.   A meche of lint or  linen, placed at the lowest part of the
division, and penetrating into  the  interior  of the bladder,  is all that
would in  reality be proper in a case of this kind.  To  this  we might
add a strip of adhesive plaster above, and the injunction to the patient
not to make any movement which would  be calculated to push the
viscera towards the peritoneal wound.
   D. Resumi upon the relative value of the operations for stone in
man.—A last question which remains to be examined,  is that of as-
certaining which method in these  cases should have the preference
over the  others,  as a general  method.   To solve this problem it is
first necessary to take  into consideration  those accidents which ter-
minate fatally to the patient after the operation of lithotomy, when
the case in question is that  of extracting  a vesical calculus in  man.
Hemorrhage  has, in many instances, been the cause of death; in
others this result has occurred in consequence of inflammations, ab-
scesses, and gangrene in the cellular tissue of the lower pelvis, or from
peritonitis.  There are some  in whom a fatal issue appears to have
taken place only in consequence of affections of organs more or less re-
mote, such as cerebral or intestinal diseases with ataxic and adynamic
symptoms, serous or purulent  effusions into the cavities of the pleura,
and especially from numerous suppurative collections in the paren-
chymatous organs. Besides these lesions there are others which con-
stitute only infirmities, as for example, incontinence .of urine, a wound
of the rectum and urinary fistulas of every description; but perito-
nitis, inflammation of the cellular tissue of the pelvis, (Arch. Gen. de
Med., t. II., p. 387, 2d ser.,) phlebitis or purulent infection, purulent
inflammation of the ureters and  kidneys,  together with cystitis, are
nevertheless the usual  causes of death.   It is true  that recto-vesical
lithotomy exposes less  than any other to the danger of  pelvic suppu-
rations and  metastatic  abscesses ; but in this we have more risk of
inflammations  of the  bladder and intestines.   It much more  fre-
quently gives  place to urinary fistulas, and without allowing, as is
generally believed, the  extraction of large-sized  calculi,  with less
danger than the others.  Hypogastric lithotomy, while it is rarely
accompanied with hemorrhage, is exempt from the danger of fistulas,
and almost always also from that of inflammation of the bladder, in-
continence of urine, intestinal inflammation, or multiplied collections of
pus in the remote  organs.   It admits of the extraction of  stones of
the largest size, and is not of difficult execution, but the wound of the
peritoneum is in itself exceedingly dangerous, should there supervene
from  it an inflammation  of this membrane.   It is proper  to  add
that   infiltrations  and   purulent  and  gangrenous  destructions  of
the pelvic cellular tissue,  are nowhere  to be  more  apprehended,
and  that  nowhere are we possessed of  fewer means of avoiding
them.
  Perineal lithotomy, when it goes beyond the limits of the prostate
exposes, though in a less degree, to the risk of the same infiltrations,
to the wounding of the vessels of the rectum in some cases, to recto-
» 
640
NEW ELEMENTS OF OPERATIVE  SURGERY.
vesical  fistulas, or to recto-urethral  or urethral only, to incontinence
of urine, and also to metastatic suppurations, more than the two pre-
ceding processes ;  which appears to me to be  owing to  the  fact,
that on one hand it more frequently involves large veins  which be-
come inflamed, and on the other gives rise to small suppurating col-
lections, which develope  themselves  in  the neighborhood of the
wound, and the pus of which is absorbed  by some means  or  other
into the general circulation.   This operation, when confined within
the periphery of the gland, must, from its enabling us to  avoid the
arteries as well as  the intestine, be but rarely followed by idiopathic
or symptomatic abscesses, and has scarcely any other inconvenience
than that of not making an  opening sufficiently extensive for very
large sized calculi; but in  such cases the bilateral operation or re-
peated debridements after the manner of M. Vidal, present an  ade-
quate resource ; while the incontinence of urine or the urethal fis-
tulas, which might be apprehended under such circumstances, are
of not sufficiently frequent occurrence, nor  so difficult of cure,  as to
be calculated to give rise to any uneasiness; so that perineal cysto-
tomy is  still the one which possesses in reality the  greatest  number
of advantages, and which, in the last  analysis, deserves to  have
the preference as  a general method.   According  to this opinion,
recto-vesical  lithotomy would be allowable  only as  an exceptional
method;  for example, when tumors, ulcerations, and alterations, in a
word, of the perineum to a greater or less depth, do  not admit of
our passing through this  region ;  or again, when the  calculus is
found lodged by one of its extremities in the prostate, or when this gland
is diseased and ulcerated, or the seat of an excavation, which would
cause an incision upon its sides to be attended with too much  diffi-
culty or danger ; and  finally,  when the stone appears  to have atten-
uated or ulcerated the recto-vesical septum itself.   The high opera-
tion would be reserved  for very large calculi and  for children, and
where the bladder  could be distended with facility, or where the em-
bonpoint of the patient did not render it too difficult of  execution.
It is, however, to be remarked that  if obesity is an obstacle in the
hypogastric operation, it possesses on the other hand  the  advantage
of placing the peritoneum at a distance from the instrument by the
interposition of the adipose matter which ordinarily accumulates be-
tween this membrane and  the  walls of the  belly.   Finally, those
cases in which there is a horny degeneration, or thickened condi-
tion of the walls of the bladder, would also come under the class  of
those which belong to recto-vesical lithotomy, should it not be possi-
ble to have recourse in them to the perineal operation.

                   § X.—Lithotomy in  Women.

   Women, who are much less exposed  to calculous affections than
men, are also much more easily cured of them by an  operation.  In
them the urethra is straight, short and  large, so that small  calculi
pass through it with the greatest facility, and rarely enlarge in size
in the interior of the  bladder.  Nevertheless, they are met wi' i in
this sex, and we have  recourse to the same means to get rid of  t:<em
as in the other.  Lithotomy in women is also performed by the hi»h
4 
LITHOTOMY.
641
 and the low operation.  If the first of these methods should require
 no remark, because it is subjected in every respect to the same rules
 as in man, it is not so with the second, where we  find the recto-ves-
 ical replaced by the vagino-vesical operation, and  the lateralized ope-
 ration by the incision into the urethra.
   A. Examination of the methods.—Some surgeons  have alleged
 that all the lithotomic processes  applied to man  might be also em-
 ployed in women  ; this assertion is certainly incorrect.  The  great
 operation, for example, never could be  put in practice in women.
 The same nearly may be said of the  bilateral taille, at  least when
 applied to the lower  side of the urethra.  There remain  then  the
 lateralized, the little, and the vaginal processes.   Calculi, moreover,
 of every description, have been noticed in this sex as  in man.   A
 woman who was  operated upon by M. Seutin, (Encyclogr.,  1839,
 p. 157,)  and who died,  exhibited  debris of a foetus  in  the ovary,
 which extended into the bladder, where was found a tooth.  In  the
 girl mentioned  by M. Gendron, (Bull, de la Fac. de Med., 6th year,
 p. 132,) the calculus had a needle case  for its nucleus; in the case
 related by M. Poupinel, (lb., 6th year, p. 65, and  148,) an exostosis,
 twenty lines long  at the upper strait led to the supposition  of a cal-
 culus.  The needle which served as a stem to the stone, in the case
 related by M. Macario, traversed the uretro-vaginal septum, in such
 manner  as to render coition excedingly painful  by  the  punctures
 which it inflicted upon the husband. The siliceous calculi noted by
 M. Hill,  (Gaz. Med., 1834, p. 135,) and M. Segalas, evidently  came
 from without.   M. Janson and M. Castara have found some that
 were of very friable texture.
   I. Ancient processes.—Lateralized method, or rather lateral  litho-
 tomy.  The Greeks, Arabs,  and surgeons of  the  middle ages, per-
 formed lateral, or  lateralized lithotomy in woman in the same manner
 as in man.  Before the knowledge of the sound, they confined them-
 selves to making the calculus descend  into the neck of the bladder,
 where they fixed it by means of two  fingers bent into a hook, and
 introduced  into the vagina, or if it was a virgin, into  the rectum.
 They then cut from the skin towards the bladder, all the tissues over
 the stone, in an oblique direction, from  above downwards, and from
 within outwards.  F. Jacques modified  this process only by making
 use of a sound to  stretch  the parts, which enabled him to dispense
 with looking for the stone with his fingers  in the vagina or rectum.
 The trials made by this monk in the presence of Marechal and Mery
 having demonstrated,  as  an accurate knowledge of the anatomical
 arrangement of the parts would have  anticipated, that the vagina
 was almost constantly wounded,  and that the rectum itself might be
 implicated, it was speedily abandoned ;  so that at the present day no
 person either recommends or practices it.
   II.  Method of Celsus.—Celsus expresses himself in so obscure a
 manner, or with so few details in regard to lithotomy in women, that
 it  is  quite  difficult to ascertain  precisely what he means  by  these
 words : Mulieri vero inter urince iter et os pubis incidendum est, sic
ut utroque loco plaga transversa sit.  Some persons, and M.  Des-
 ruelles among others, have supposed that at the time of this author
they made a transverse or semilunar incision between the  meatus
   vol. m.                    81 
642
NEW ELEMENTS OF OPERATIVE SURGERY.
 urinarius and the roots of the clitoris, and that they cut down upon
 the stone through this, in the same way as we lay it bare in man, be-
 tween the  anus  and the root of  the scrotum.  But, as has been re-
 marked by M. Coster, it is not impossible that Celsus had in view the
 incision into the urethra itself, instead of that which I have just indi-
 cated.  The method which consists in penetrating by the vestibulum
 is moreover so defective in everv point of view, that it was not worth
 the  trouble of  disputing M.  Lisfranc's title  to  it.  This method,
 which was defended by M. Meresse at Montpeher, m 1823, and  de-
 scribed in great detail in the Archives for the year 1824, is performed
 in the following  manner : a sound is first introduced into the bladder
 in such a manner that its groove or convexity may be turned upwards
 and forwards, in place of resting downwards  and backwards  as in
 man.  The surgeon placed in front  of the perineum, makes a semi-
 lunar incision between  the clitoris  and  the external orifice of  the
 urethra ; divides in succession and layer by  layer, all the tissues
 which separate the  vestibulum from the interior  of the pelvis ;  ar-
 rives at the anterior  surface of the  bladder at the point where  the
 urethra unites with the neck of this organ ; encounters the sound and
 cuts  down  upon  its groove ;  prolongs the incision upwards, by turn-
 ing the cutting edge of the bistoury in this direction, and then down-
 wards in such manner as to make a longitudinal division in the pos-
 terior portion of the urethra ; or he  incises the bladder transversely
 to the extent  of an inch or 15 lines.  In  whatever manner we  pro-
ceed, the calculus will always be compelled by this operation, to pass
 through the narrowest part of the pelvic cavity.  The bladder, when
 it is opened longitudinally, will scarcely admit of extracting from it
 stones which  are somewhat voluminous.  If  we should divide it
 transversely, the unavoidable separation of the lips of the wound in a
 region surrounded with  so great  a quantity of cellular tissue, would
 not probably fail to give rise to  those infiltrations, and abscesses  so
dangerous,  which have  been described  in speaking  of hypogastric
 lithotomy.
  III.  Vesico-vaginal lithotomy.—The  idea  of extracting vesical
 calculi through  the vagina  goes back at  least as far  as to  the
 time of Rousset, since this author states  that he removed 11 of them
 through this passage, in  a woman in whom the bladder protruded at
 the vulva.   F. de Hilden (Bonet, Corps de Med., p. 439,) followed
 the example of Rousset, in a case in which the  vesico-vaginal septum
 had been partially perforated by  the stone, and again in another case
 in which thf* urinary bladder had  been  ruptured  at the time of ac-
 couchment.  Ruysch also performed this operation, and extracted 42
 calculi from the  same woman, but it was a case in which  there was
 an eversion of the vagina.   Tolet acted  in the same manner under
 circumstances nearly similar.  In 1740  Gooch met with a female in
 whom the inflammation had  ulcerated the vesico-vaginal septum, and
 which he cut into in  order  to extract the calculus, weighing 3 or 4
 ounces.  M. Faure exhibited in 1810, to the faculty of Paris,°a frag-
 ment of wood which he had taken from the bladder of a vouno- girl,
 by means of an incision into the vagina.   M. Clemot performed^vagi-
 nal lithotomy for the first time in 1814, in a patient  21 years of age,
 and  soon after repeated it  in  another  female.  Since that period 
LITHOTOMY.
643
he has had recourse to it a third time.   A short time subsequently,
M. Flaubert made use of the same process in order to extract a pin
and needle, which had become the nucleus of a calculus, in a child 11
years of age.  In 1816 he operated upon a woman 33 years of age,
who had a stone of the size of a nut; and afterwards upon a woman
of 40 years of age, in whom the stone  was nearly the size  of a bil-
liard-ball.   On the 10th of December, 1818. he operated upon a fourth
woman, who was 21  years of age, and  extracted  a calculus of the
size of a large nut.  M. Philippe, of Reims, extracted through this
passage, in a pregnant woman, a calculus weighing 9 ounces, which
he has transmitted to me.  A fistula remained behind.   A large stone,
having a fragment of wood 3 inches and 3 lines long, for a nucleus,
was extracted  in the same manner, by M. Castara, (communicated
by the author, November 26,  1838,)  from the bladder of a maiden,
who was 45 years of age, and who recovered.  The female that M.
Macario (Bull, de Fer., t. II., p. 262,) operated  upon, and  who had
a calculus which  had become developed upon  a needle, which was in
the substance of the vesico-vaginal septum, also recovered.  M. Rigal
(Coze, Journ. Univers. des Sc Mid., September, 1819,) also operated
through  the vagina,  in  1814, on a woman 40 years of age, and in
whom the calculus weighed two and a half ounces.   The same practi-
tioner had already performed this operation several years before, in a
woman aged 38, and who had had a  calculus  of considerable size for
the space of 8 years.  Another  instance has been published by M.
Lavielle, (Bull, de Fer., t. VIII., p.  72,)  and  M. Rigal, the son, has
furnished another instance.  So that  science now possesses about 25
instances of the vagino-vesical operation, without  speaking of those
which Gooch ascribes to various practitioners in his country, but of
which he  has furnished no detail.
  B.  Operative process.—Many  surgeons who have performed this
operation, have omitted to mention the  process which  they adopted.
F. de Hilden, who was the first  to recommend it  formally, advises
that a scoop of small calibre should be  introduced into the  bladder,
through the urethra, and that it should embrace the calculus with its
concavity, and then depress  it by bringing it down near the neck of
the bladder ; finally, that the surgeon should incise upon  the  projec-
tion which is thus made in the vagina, and then complete the extrac-
tion of the stone through this passage.  The process of Mery, which
consists in substituting the ordinary sound for the scoop  (curette) of
Fabricius, in such  manner as to divide the vesico-vaginal septum upon
the groove of that instrument, was calculated to cause the method of
the Swiss  practitioner to be  forever rejected.   This, in fact, is the
process which  with certain  modifications modern  surgeons  have
deemed it advisable to follow, some by associating with it a gorget to
depress the posterior wall of the vagina with its outer extremity, while
the other end butts against the sound, in front  of the neck of the ute-
rus ; and others, like M. Flaubert,  for example, in confining themselves
to the introduction of the bistoury flatwise on  the right forefinger, in
order, afterwards to turn its cutting edge upwards, to cut the septum
from before backwards, or from behind forwards, to within a greater
or less distance from the meatus urinarius.
  I. Position of the patient.—In placing the woman as for ordinary 
644
NEW ELEMENTS OF OPERATIVE  SURGERY.
lithotomy, we may, without any doubt, attain  our object.  Never-
theless it appears to me evident that if she were upon her belly, with
her thighs and legs flexed, it would be still  more easy to make the
incisions that are necessarv.   The instruments required  consist only
of a sound, the gorget of Marchettis, a  straight  bistoury and the
tenacula.   The  sound  is  first adjusted,  with the  plate  raised up
towards  the  pubes in  order to depress the bas fond of the bladder
upon the median  line.  An assistant is charged with keeping  it in
this position.   The gorget having been introduced to the bottom of
the vagina, is  then  given in charge of a  second assistant,  who
depresses its  handle,  while taking "care  that  its  other  extremity
serves as a point d'appui to the sound, and that its groove looks
upwards and  forwards if the woman is placed on her back; and
downwards and backwards on the contrary, if she is on  her belly.
The surgeon separates the  labia majora  with  the thumb and first
fingers of his left hand ; seizes the bistoury in the manner of a writing
pen and directs its point behind the urethra, that is to say, to an inch
at least in depth  into the vagina; inserts  it into  the  groove of the
sound, then makes it glide along this instrument to the distance of
eight  or ten  lines, or  more if  it is necessary, and terminates by
depressing it  a little in order to make it fall into  the  groove of the
gorget.   We might also hold the bistoury in  the second position, that
is  to say. with the handle in  the  hollow of the hand and the cutting
edge turned towards the bladder, in such manner as to introduce its
point  to  the depth that may be  required, and to divide the septum
from behind  forwards, and always upon the groove of the  sound.
These two methods differ so little as to their ultimate result, and even
in respect to  the facility of the manipulation, that we must leave the
preference to  be given to one over the other, to the choice of the
operator.   There  is  no doubt  also that the  surgeon might himself
hold the sound with his left hand, while with his right he incises in
the manner that M. Flaubert operated; or as M. Clemot recom-
mends, he may on the contrary seize the gorget in order not to be
interrupted by the assistant at the time of making the division of the
septum.  We might also, if necessary, dispense with the  gorget by
adopting the course of the surgeon of Rouen; that is, introduce the
bistoury protected by the  palmar surface  of the forefinger, into the
interior of the vagina, in order to make the opening into the bladder
without having need of liny other assistance than such as would keep
the patient steady; but it cannot be denied that the operator, with
his two hands free, is more at his ease to make the principal incision,
and  that the gorget  possesses  the  advantage  of stretching  and
exposing the  parts which  are  to be divided; only that it would be
advisable that this instrument should have  a handle which  is bent
into an  angle, and that its groove should  terminate without any cul
de sac.
   II.  The  incision, if commenced at some lines  behind the meatus
urinarius, in such manner as to include  a greater or less extent of
the lower wall of the urethra, as  in the process followed by M.  Flau-
bert, would, in the first place, have the inconvenience of not favoring
in any respect the extraction of the calculus, and in the second place,
of rendering the cicatrization  of the wound more tedious and diffi- 
LITHOTOMY.
645
 cult.   It is better therefore to imitate MM. Clemot, Rigal, &c., and to
 commence only at the point of the trigonus vesicalis, if we incise from
 before backwards, or to terminate there in case we should prefer to
 make the incision from behind forwards.  As the vagina has a length
 of from three to four inches, there will  still  remain, when we adopt
 this process, an extent of over an inch, which may be divided without
 danger.   Moreover as the tissues possess so great a degree of distensi-
 bility, it is unnecessary to give a greater extent to the opening than
 appears to be required by the supposed volume of the calculus.   M.
 Faure, the oculist, (Observ. sur I'lris, &c, p. 60, 1820,) who recom-
 mends that we  should traverse the vesico-vaginal septum by a very
 oblique incision from before backwards, states that he cured in this
 manner, in 1808, a young girl without any fistula ensuing.
   III. Extraction of the Stone.—The  incision  having been made,
 the sound is to be withdrawn.  If the calculus does not present itself
 of its  own accord in the wound ; or if it does not fall spontaneously
 into the vagina as has  sometimes happened, the operator  proceeds
 immediately to search for its situation and relative position by means
 of the left forefinger ; he then extracts the calculus by means of suit-
 able  tenacula, regulating his course  by the rules above laid down.
 When the stone is of large size or when we  operate on a young girl,
 this extraction may, in consequence of the narrowness of the vagina,
 be attended with some difficulty.  M. Flaubert, in a case of this kind,
 was obliged to break up the foreign body and remove it in fragments.
 Nevertheless,  as the  canal which is to be passed through  is exceed-
 ingly dilatable, it is scarcely to be conceived that it would present an
 insurmountable  obstacle to the termination of the cystotomy.
   IV.  The stone being once removed, the woman is to be replaced
 in bed and submitted to the same attentions  that are required by the
 usual  sequelae of lithotomy.   These sequelae   in the vagino-vesi-
 cal method are generally of a very simple character;  up to the
 present time there is no case related in which they have resulted in
 death.   In most cases  scarcely any  fever  supervenes.  No large-
 sized  artery can be wounded.  The peritoneum is too far off to run
 the slightest risk, and the cellular tissue of the septum is too dense to
 admit of the possibility of a urinous infiltration.   But the wound does
 not always cicatrize  agreeably to the expectations of the patient and
 operator.   Its  position alone, must have already led to the presumption
 that in many cases it would be transformed  into a fistula, and expe-
 rience  nas unfortunately confirmed this anticipation ; without count-
 ing that it might well have occurred in some  of the patients  who
were first operated upon, though no mention may have been made
of it by the surgeons.  It is at least certain that out of three cases of
M. Clemot, he has found one followed by a fistula ; that three of the
patients treated by M. Flaubert were affected  in this manner ; and that
those related by M. Rigal the son (Rev. Med., 1831,1.1., p. 489,)  and
M. Philippe, were not more fortunate ;  from whence it follows that
this accident is met with in at least one  case out of four.  M. Coste
supposes that it  might be prevented by  reuniting the wound by su-
ture  immediately after the extraction of the calculus ; but vaginal
cystotomy would then  become an exceedingly tedious operation.
There  is also reason to doubt, after the trials  of  this kind in cases of 
646
NEW ELEMENTS OF OPERATIVE  SURGERY.
  ordinary vesico-vaginal fistulas, notwithstanding the  fortunate re-
  sult of M. Coley, (L'Exper., t. III., 1839,) if we should by this means
  be enabled to obtain the success which M. Coste appears to anticipate.
    C.  Urethral Alethods.—For a long time  perineal  lithotomy in
  women has been almost exclusively performed by making an incision
  into  the  urethra; this  canal, however, is so dilatable that  a long
  while ago the idea was suggested that we  should extract the cal-
  culi  without making any  kind  of incision.   Bartholin speaks of a
  woman who expelled one which had a diameter of over two inches;
  Borelli cites another in whom was as large as the finger; and Middle-
  ton relates  that a woman,  during  a paroxysm of coughing expelled
  one which weighed four ounces.   Heister has collected examples of
  the same kind, in which it may be seen that calculi as large as a nut
  or even  a pullet's egg have  been ejected  through this passage ; F.
  Collot mentions one of the size of a goose egg, and which had  caused
  ischuria  for the space of eight days before it was expelled ; Moly-
  neux (Transact. Phil.-Chir., vol. IV., p. 227) states that he has seen
  another which weighed two and a half ounces ; while  the one men-
  tioned by M. Yellowly weighed more  than three  ounces.  We  find
  in Planque, (Bibl. de Med., t. IX., p. 467, in 4to,) instances of  calculi
  of still larger size that were expelled in the same manner.   Kerkrin-
  gius, Morand and Grunewald, and scientific collections both ancient
  and modern, relate cases which are no less extraordinary.  The one
  which M. Segalas has exhibited, (Rev.  Med., 1836, t. II., p. 279,)  had
  no less than an  inch in its  smallest diameter,  and M. Simon, (Ibid.,
  1826, 1.1., p. 133—Journ. de  Graefe und Walther, t. VI., p. 163,) has
  mentioned one  which was two and a quarter inches in length  and
  one inch in breadth.   A woman  that fell under the  notice of M.
  Harris, (Gaz. Med., 1838, p. 744,) expelled a calculus which was two
  and a half inches long, by one in  breadth, and weighed 651  grains.
  Though   some  of these  calculi may have been  expelled  from the
  uterus and vagina instead of  having been formed in the bladder, it is
  nevertheless indisputable that many of them  have in reality come
  through  the urethra, and that in certain cases this enormous dilata-
  tion has not been followed  by incontinence of urine.
    I.  The method by dilatation, which grew out of these facts, is per-
  formed in two principal modes: in one we proceed rapidly by means
  of metallic  instruments ; in the other, on the contrary, we act  with
  extreme caution, and by means of  permeable substances temporarily
  retained in the passage.  Tolet is the author of the first method and
  Douglas  of the second.
    a.  Sudden dilatation.—The process of  Tolet consists in introdu-
  cing into  the bladder the dilating instruments of the great operation,
  and in moderately separating their branches until we are enabled to
  pass  the fingers and tenacula between them, in order to reach the cal-
  culus.  Since that period the ancient dilating instruments have been
  replaced  by the following  process.  A grooved  sound serves as  a
  conductor to a gorget which is narrow in its anterior portion, and
  which widens rapidly towards the handle.  Bv means of this  gorget
/ the fore  or little finger  of one of the  hands afterwards dilates the
f urethra from before backwards, in order to make a passage for the
' tenacula  ; but in whatever  way we effect this dilatation, it is a  painful 
LITHOTOMY.
647
operation, and  so much so that many women  are  utterly unable  to
support it;  it  is moreover  frequently followed  by incontinence of
urine, laceration of the urethra, &c.
  b. Gentle dilatation.—Douglas supposed that he could remedy the *
inconveniences of sudden dilatation, as proposed by Tolet, in opera-
ting by means of a tent which was made of sponge or of dried gentian
root.  This is the way in which those practitioners  still proceed, who
suppose  that they can  dispense with an incision into the urethra.
The little cylinder of the coecal appendix introduced  empty  into the
bladder, and then filled with water, and brought out from behind for-
wards, as proposed by Bromfield, the dilator of the same description
contrived by Arnault, and the little speculum of Weiss, (Bull, de Fer.
t. I., p. 82,)  are no  better, while the  sponge in fact has this advan-
tage, that it enables us to introduce  through  its centre  a  catheter
which allows the urine to escape, should we  propose to leave the
dilator in its place for a long time.   We should be wrong, however,
after all in supposing that this kind of dilatation  is  much  less painful
than the other,  and that it protects us better from the  dangers of in-
continence of urine and the different accidents which that is considered
chargeable with.  It is certain that a pure and simple incision, as it is
performed  at the present day, does  not involve  any greater danger,
that it causes less suffering, and that it enables us to afford more prompt
relief to the patient; so that dilatation, whether gentle or sudden, is not
in reality adapted but to those calculi whose greatest diameter  does
not exceed  five or six lines.
  II. Uretrotomy.—The uretral incision may, if necessary,  be  per-
formed on any  part of the two upper thirds of  the circumference of
the canal.
  a. Fleurant has proposed to divide the urethra on both sides at the
same time,  by means of a double  lithotome,  introduced shut up, and
drawn out open, and to commence  the incision at the  neck of the
bladder and terminate it at the meatus urinarius.   Louis, who adopts
the same principle, recommends that  we should incise from before
backwards.   For that purpose he had contrived a flattened sheath
which was  open on its sides, and  in  which he plunged from  without
inwards a blade with a double cutting edge.   Le Blanc,  to whom he
communicated  his invention, remarked to him  that an  instrument
which had a cutting edge on one side only, and  a sheath which was
open in that direction only, would answer the purpose.  But  the pro-
cesses which have been based upon such instruments have at the pre-
sent day completely fallen into disuse, and uretral taille no longer re-
quires for its execution any other than a straight bistoury and grooved
sound, or the lithotome of F. Come ; unless we should desire to revive
the  process of Fleurant, in which case the double  lithotome of Du-
puytren would  obtain a new application.
  b. The most ancient process and the one which has been the longest
followed, is that which consists  in introducing into the bladder a
grooved sound, to serve as  a guide to a  long straight bistoury, by
means of which we divide obliquely from  above downwards, and
from the right to the left, through the whole extent of the urethra.
But this method, which M. Klein, (Rust's Handb. der Chir.,  vol. II.,
p. 177,) calls cystenchenotomy, one which F. Come and  Dupuytren 
648          NEW ELEMENTS OF OPERATIVE SURGERY.
have rendered still more simple by making use of the concealed litho-
tome in place of the bistoury and sound, and which Kern (Ibid., vol.
II., p. 183.) performed with a male catheter, the groove upon which
he turned to the left and downwards, was frequently followed by a
wound of the  vagina, and moreover, if the  incision  was carried a
little too far, exposed to the risk of dividing the superficial vessels of
the perineum, and even the pudic artery itself.   MM. Scheuring and
Schroeger, (Ibid., vol. II.,  p. 181,) who, in operating also with the
grooved sound and bistoury, made their incision transversely, have
in this matter added nothing useful to this proeess.
  c  Process of Collot.—This operative process, therefore, ha3 been
generally abandoned, since it has  become the practice to incise  the
urethra directly upwards.   The origin of this last process, which  is
ascribed to A. Dubois, goes back as far at least as to the sixteenth
century.  It is to Collot to whom Pare, after having given the figure
of a grooved sound, ascribes the honor of this process : "Other prac-
titioners," says he, " operate in another manner, as I have frequently
seen done by Master Laurent Collot; it is this, that  they in  nowise
place their fingers within the seat, nor within the neck of the uterus,
but content themselves with inserting the conductors into the  urinary
passage, and then afterwards make a small incision altogether above,
and in a straight  line from the orifice of the neck of the bladder,  and
not upon one side, as is done in males."   At the present day this ope-
ration,  after the  modification under which it has been  revived by
Dubois, is performed in the same way as the preceding, by means of
the sound and bistoury, or with  the concealed  lithotome.  In the
first case, we introduce a large sound terminated in a cul desac, and
with its groove turned upwards.   The surgeon holds the instrument
at its plate with  his left hand, and by  means of this depresses the
front part of the vagina with a certain  degree of force.  With the
right hand he  conducts upon it a narrow and very  sharp bistoury,
by means of which he incises the upper wall  of the urethra through-
out its whole  extent, together  with the surrounding  tissues, as high
up as to the infra-pubic ligament.  By  this means  we obtain an
opening of from 6 to 8 lines, which is sometimes  increased  from 8
to 10 at the moment of making tractions upon the stone.  Neverthe-
less it would be dangerous to attempt to extract through a passage
of this kind a calculus of over an  inch  or 15 lines in diameter.   1
have seen M. Bougon remove one of this size  in  a  young woman
who recovered perfectly, and M.  Thomas of Tours was no less for-
tunate  in a similar case.  The  one mentioned  by M. Castara,  (let-
ter of the 19th March,  1839,) was  as  large as an egg,  but it was
crushed by the simple pressure made  upon the tenacula.  It is im-
portant when  we withdraw the tenacula to rest them with a certain
degree  of force against  the lower plane of the urethra, and raise  up
their handles in such manner that they may act in the  direction of the
axis of  the lower strait.   Otherwise the calculus and the instrument
would  butt  against the symphysis,  and the surgeon would in  this
manner surround himself with serious difficulties, and at the same time
would  expose the woman to dangerous  contusions.  A good operator
in one of the  hospitals of  Paris in 1824, was for a long time embar-
rassed by this obstacle, though the calculus, which was extracted with 
LITHOTOMY.                        649
 extreme facility by changing the direction of the tenacula, was no
larger than a partridge egg !   In certain cases also the calculus may
be extracted with  so much facility that a simple dressing forceps will
answer the purpose.   M. Gaspard, (Bull. Aled. de Bordeaux, 1833,
p. 171,)  while  in  a remote part of the country,  and  without  any
assistant or special instruments at command, succeeded by this means
after  having incised  the urethra with a bistoury guided  upon a
grooved sound.
  B. Appreciation.—It is perceived from the above facts that no kind
of perineal lithotomy will allow  of the extraction of large stones in
women.  The  lateral or even  the lateralized incision  itself, would
not, under such circumstances, be of any great advantage.   As the
superior incision is located at the top of the arcade, it can  necessa-
rily furnish  us with but  a very  limited  opening.   The  bilateral in-
cision  would present more  advantages ;  but experience has not yet
shown  that it  could  be performed  with any positive  prospect  of
success, and reasoning induces us to  apprehend that the urethra di-
vided in this manner into two halves, might allow of dangerous urin-
ous infiltrations, or give  rise to  an incurable  incontinence of urine.
Nevertheless, I am of opinion with Dupuytren, that it would be ad-
visable to re-examine this question and to decide upon it by the evi-
dence  of facts.  If now  we should take into consideration that in the
feminine sex,  lithotomy is  in  the majority of cases  requisite for
calculi  of a large  size,  we shall find ourselves immediately reduced
to the  necessity of making choice between the  vaginal and the  hy-
pogastric operation.  The fistulas which too frequently follow after
the first, constitute an infirmity which is so disgusting, and  so often
incurable, that  we would rarely decide  upon performing  it, without
being very  certain that it was not possible to succeed in any other
manner.  Now the second, all other things  being  considered, being
more  easy, in  consequence of  the less considerable height of the
pubes, and the  more marked projection of the bladder above the pel-
vic cavity, and having at every  epoch been considered  less danger-
ous than in man, ought in my opinion to be preferred  in all those
cases  where the  urinary organ retains  a certain  degree  of dilata-
bility ;  so much the  more  so,  inasmuch as those calculi which  it
would be found impossible to extract by the incisions into the urethra,
would require in the vesico-vaginal septum too great  an opening to
exempt us from the danger of producing a fistula in that region.  In
conclusion, dilatation in my view appears to be adapted to small cal-
culi ; the upper incision to those which  do not exceed the size of a
small egg; while the oblique incision should be made trial of in those
cases only wher,e the stone is a little larger, or  where the vagina  is
not sufficiently  dilated to make it almost impossible to avoid its  le-
sion.   While vaginal lithotomy would be adapted  only to those  cal-
culi which were as large as a  pullet's, or  at  most, a turkey's egg,
upon the supposition that we were not disposed upon any account to
resort to the hypogastric operation, which nevertheless is the only
one that in reality  could be adopted where the stone is still more vo-
luminous.
  vol.  in.                      82 
650
NEW ELEMENTS OF OPERATIVE SURGERY.
                    Article IV.—Lithotrity.

   Lithotomy, notwithstanding the improvements which it has under-
gone, is still of so dangerous a  character that efforts  are constantly
being  made, to get  rid  of the necessity  of it,  and to substitute
for it a less  painful operation.  Many persons conceive  that  this
result, which is  so desirable,  has been achieved  by modern  sur-
gery ;  and that by means of lithotrity, we  shall henceforward have
it in our power to dispense with the operation of lithotomy, at least
in an  immense  majority  of cases.   We shall see  farther on what
foundation there may be for anticipations of this kind.   Lithotrity,
or the crushing of the stone, consists in the breaking up of the  cal-
culi into fragments, (le  morcellement,) and  their extraction  after-
wards through the natural passages by means of special instruments.
It comprehends in its largest acceptation the pure and simple extrac-
tion, crushing, pulverization, breaking up, perforation, and  tritura-
tion of calculi in the interior of the urinary bladder itself, or of the
urethra.   The designations of lithopriny, lithodialysis,  lithotripsy,
and lilhocenosis, which it has  been proposed to substitute for the
term lithotrity, being no more free from objections  than  this last, do
not deserve the preference which has been contended for by those
who have proposed them.  The idea of extracting  calculi entire, or
after having broken them  up, and without incising into the organs, is
far from  being  new.  It has attracted  attention at every epoch, at
least for those calculi which are lodged in the urethra.   It also some-
times  happens that the stone crumbles to pieces of itself  in the inte-
rior of the bladder.   A  patient mentioned by M. J. Harding, (Gaz.
Med., 1838, p. 777,) and  who died  at the age of 81  years, without
having undergone an operation, had 50 calculous fragments resulting
from the spontaneous disintegration of a stone in the  bladder.  A fact
almost in every  respect  similar was seen  by M. Segalas, and pub-
lished by him.  I saw a case somewhat analogous in 1836, at  the
hospital of La Charite.  Albucasis  had already made  mention of an
instrument which would enable  us to seize calculi at the remote por-
tion of the urethra; the  sheath forceps, with three  or four  branch-
es, as  described and figured in the Bibliotheque  of Manget,  under
the name  of  Asta,  appeared to F. de  Hilden, to be calculated to
effect  the same result.  A tube with three elastic  branches was made
use of for the same  purpose  by Sanctorius.   Franco  had contrived
for this object  a vesical quadruple, and  Pare a kind of augur or
turrell, which he conducted  upon the calculus  through  a  can-
ula.   F. de Hilden used a forceps with three branches, which was so
constructed as to  crush the stone after  having embraced it.   How-
ever, though  it may have appeared to almost°all authors  to'be prac-
ticable to seize small calculi, and to  perforate and break them  up, in
the urethra, it is by  no means as clearly demonstrated that their' in-
struments were ever introduced  farther than this point, to carry out
the same indication.  Nevertheless, an Arabic  author, who is  evi-
dently no other than Albucasis, says, in a work in which he is spoken
of under the  name of Alsaharavius, or Acaravius, (Liber Theor  nee
non Pract., 1519,) that we must " cautiously introduce into the blad-
der a fine (subtil) instrument, called Maschabarebilia, in order to seize 
lithotrity.
651
the stone and to crush it  if it is soft, and then to extract it."  Alex-
ander Benoit also remarks, that we may crush the calculus by means
of metallic instruments, and without making  any wound in the  or-
gans ; it appears finally that Sanctorius, (Haller, Bibl. Chir., t. I., p.
213,) Franco, and F. de Hilden, also went so far as to look for small
calculi in the ui'inary bladder itself;  but  the few facts furnished by
these authors are too vague to have any great  weight in this ques-
tion.  I might say the same of Aretino, (Strangalament. liter. Post.,
&c.,) who, in his posthumous surgery, speaks of a forceps with three
branches, designed for extracting gravel from the urethra  and blad-
der.  In the last century, Hoin related the history of a monk of Ci-
teaux, who, by means of a flexible sound, and a steel stem termina-
ting in a bevelled edge, had succeeded in breaking up a ston*e in him-
self, by striking upon it small strokes with a mallet, in the same man-
ner as upon the  chisel of a  statuary.   The journals of Calcutta, and
afterwards Marcet, (on Calculous Disorders,  &c, p. 20,) have made
known  an  experiment which is more conclusive, viz., that of Major
Martin, who succeeded upon himself in reducing a stone into powder,
by means of a file which he introduced into the bladder through a
curved  sound;  which did not prevent him, it  is said, from dying of
stone in 1800.   As with  M. Civiale, so with me, it has been impossi-
ble to find  the work of D. Marco, published at Venice in  1799, and
entitled A  New  Manner  of Dividing the Stone in the Bladder, &c.
Though the  forceps of  Hales, called  Hunter's, enabled Desault to
bring to the outside very small vesical  calculi, and  though M. A.
Cooper, who has modified it, has extracted with it in this manner in
a chimney  sweeper near  80 calculi from the bladder; all this  never-
theless  did not  by any  means  constitute a method;  nor  did  the
breaking up of the calculi, by making percussion  upon  them with a
sound, as recommended by Thomassin,'or with a catheter, according
to the manner of Rodriguez, furnish anything very conclusive, not-
withstanding the much better systematized experiments made by M.
Gruthuisen and M. Eldgerton, which last also with the intention of
breaking up the stone in the interior of the bladder, likewise made  use
of a curved catheter, (sonde,) in which he introduced a grater (rape)
in order to break down the calculus by a movement backwards  and
forwards, (va el vient.)  Nevertheless, the project of M. Gruthuisen
though not used  in practice, and perhaps not practicable, went farther
than any other.  This surgeon has delineated  numerous instruments,
and made repeated experiments, and demonstrated  that we may in-
troduce into the  urethra straight canulas of from four to five and six
lines in diameter.  Though  his principal  object was to dissolve  the
vesical  concretions by means of  the galvanic  pile, he nevertheless
contrived an apparatus to break them  up ; which apparatus is com-
posed of a  straight canula, a noose of brass wire which opens at its
extremity in the bladder, and of a perforator which may protrude from
it and re-enter at pleasure.  The trials of M. Gruthuisen, however, had
like the  others passed into oblivion, when several of our countrymen,
feeling the same  want of an operation of this kind, exerted themselves
to give a permanent foundation to lithotrity.   M. Civiale. who, in  the
year 1818, endeavored to discover a means of dissolving stones in
he bladder, and had already conceived  the  idea of certain  instru- 
652
NEW ELEMENTS  OF OPERATIVE  SURGERY.
ments by which they could be grasped and broken up, maintains that
those which he now employs were invented by him.  M. Leroy, on
the contrary, alleges that M. Civiale had not at that time devised any
but unsuitable instruments, and that the  forceps  with three elastic
branches, and which is nothing more than a modification of the for-
ceps of Sanctorius or  the ball extractor of Alphonse Feri, were un-
known to him.  I remember, in fact, that  M. Leroy showed me this
forceps, the same as that which he still uses, before presenting it to the
Academy, in April, 1823 ;  and that  that which is found in the first
work of'M. Civiale, published in the course of the same year, is very
different from it, and is much more analogous to the vesical quadru-
ple of  Franco.   It is  however a difficult matter to come  to a deci-
sion on this point;  Percy, in his report to the Academy of Sciences in
1824, declared himself wholly in favor of M. Civiale ; while in 1825,
1828 and 1831, the same learned body recompensed M. Leroy,  for
having invented the principal instruments, and among others the for-
ceps with three branches.  A review,  however, of the different pro-
cesses  now in  use, and of  the various  instruments which have been
employed up to the present time, will oblige us  to return to these
questions, and  will place us in a condition to  form a more correct
judgment in respect to them.

              § I.—Examination of the Methods.

   Lithotrity comprises two methods,  which are sufficiently distinct
in respect to the instrumental apparatus used ; in one  straight instru-
ments  are  employed; while in the other, on the contrary, the  in-
struments are curved.
   A. Rectilinear method.—One of the difficulties which for a long
time embarrassed practitioners, was  that of penetrating into the blad-
der with straight instruments, so much so that lithotrity actually dates
its existence from  the time  at which practitioners ascertained  the
practicability of rectilinear catheterism.   As the straight catheter
(sonde) has thus become a principal  instrument, we cannot be sur-
prised  at the importance which has been attached by some persons
to its invention.  But  upon this point, as in almost all  those questions
which  relate to the great operations in surgery, we have only gradu-
ally arrived at the realization  of the fact, while the actual discovery
is found to  be separated by a very considerable distance  from the de-
monstration of its utility.   Though it may not  be proved  that Albu-
casis or Sanctorius, or any other  ancient author  had conceived the
idea of straight instruments for penetrating into the bladder ; though
it might be allowable to call in question the fact, that  the straight in-
struments found in the diggings of Herculaneum, by E. Clark, or in
the Officinium of a surgeon of Portici, were ever made  use  of for
catheterism ;  or though it  should be incorrect to say the Rameau  had
proposed sounds that should be altogether straight, it is at  least indis-
putable that  Lieutaud did formally make this suggestion, and that
his proposition was far from having been forgotten.   We find it in
fact reproduced in the Elements of Surgery published by Portal, in
1768, and  afterwards in the Dictionary of Surgery edited by  Louis.
In 1795, Santarelli, a surgeon of Rome, returning to this  question, en- 
LITHOTRITY.
653
deavored to prove that the urethra has no curvature in its  prostatic
portion, and that we  may, by depressing the penis, easily overcome
that which is noticed  under  the symphysis.   Lassus  held the same
language in his course, at the school of medicine, and M. Montagut
positively maintained, in 1810, that rectilinear catheterism, in a con-
siderable number of cases, is an operation as  easy as it is  advanta-
geous.  Another French  physician, M. Fournier  of Lempdes, who
was investigating the subject of lithontriptic processes, in the year 1812,
made use  of the straight sound.   Authentic certificates collected by
him, leave  scarcely any doubt upon this  subject.   The work which
was  published  in 1813 by M. Gruthuisen, finally appeared and re-
vealed the  most important proof; so that  though we attach no im-
portance to the assertion of several military surgeons, and  MM.
Larrey and Ribes among others, who  state that they have frequently
used the straight catheter in the army campaigns, it would still be
impossible  to ascribe wholly to our epoch  the invention of catheterism
by instruments  devoid of curvature, an  invention which  M. Moulin
also  in his  turn  presented a claim to in  1829. Habit, however, and
prejudices  succeeded  in predominating, and for so much the greater
reason, because the straight catheter, as an instrument for  penetrating
into the bladder, and for  giving egress to the urine, is incontestably
less convenient than the curved.   It became necessary that this kind
of catheterism  should present itself under another point  of view, to
enable it to take rank  in surgical practice.  From 1815 to 1823 seve-
ral  surgeons, feeling  more sensibly than ever the necessity of dis-
covering some  means  by which calculi could be destroyed without  a
bloody operation, exerted  themselves to obtain this result by investi-
gations, which  were undertaken about the same time, in  similar di- ■
rections, or by different processes.  While these events were transpir-
ing, the practicability of traversing the urethra by means of canulas
without any curvature, was again announced.  Though M. Amussat,
in order to prove this, supported himself principally upon an  anato-
mical error, he, nevertheless, ultimately succeeded in awakening the
attention of surgeons  upon this subject.  While   he was  in vain en-
deavoring to demonstrate how much deception had existed in relation
to the direction of the excretory duct of the urine, MM. Leroy and
Civiale  availed  themselves of this  practical  fact,  which immediately
became for them  a matter of high importance.   Up to that time
it would appear in fact, that they had  had no idea of the straight
sound for the purpose of breaking up  calculi; while the  instruments
that  M. Leroy  fn particular made use  of, were still curved.  The
observations  of Lieutaud, Santarelli and M. Montagut, and also the
work of M. Gruthuisen, which might have been of such great assist-
ance to them, had evidently escaped their attention.  We  may, there-
fore, assert with every degree of confidence, that it was from this
epoch  only that lithotrity dates  its existence.   From that time the
breaking up of the stone  has been performed by so many different
processes, that  it becomes necessary that we should enter into a suc-
cinct review of them.  In one, and which  was  the  first  that was
made trial  of on living man at Paris, nothing more was done than
to pierce the calculus  in various directions, and afterwards to reduce
it into fragments, in order to perforate them and break them up in sue- 
654
NEW ELEMENTS OF OPERATIVE SURGERY.
cession, and then to extract them  by piecemeal, should the blad-
der itself not succeed  in expelling  them with the urine.   In another
process simple  perforations were not the only means made use  of.
The surgeon endeavored by means of particular kinds of instruments,
to hollow out the calculus from its centre to its circumference, in order
to transform it into a sort of shell, which was afterwards broken up and
reduced into fragments, as in the preceding process.  In a third pro-
cess the instrument acted upon the stone, from the circumference to
the  centre, and  its effect is to pulverize it by means of an actual con-
centric crushing.  A fourth process consisted of an  effort to crunch
(gruger) and crush the siones without previously perforating them,
and this either from the centre to the circumference  or from  before
backwards.   Another process had for its object to crush  and break
up (casser) the  stone.  It was also proposed  to split it  up from  the
centre, (faire eclater par le centre.)
  I. Perforation, which was the method adopted in the beginning
by  M. Civiale,  is the  same which  this lithotritist still eulogized in
1838.  The instruments which it requires are: 1st.  A large canula
of from two to  four lines in diameter and from nine to twelve  inches
in length, and which serves in some respects as a  sheath to the other
instruments;  2nd. A  forceps or litholabe destined  to seize and to
hold the calculus;  3d. A  drill, either cylindrical and  with a triple
or quadruple point,  or with a  head and in shape of a  trephine;
4th. Auxiliary instruments,  such as a winch, rings, racks, a mandril
lathe, and the vice, &c, which serve to support the  principal instru-
ments  outside,  and to  make them  manipulate in the interior  of  the
bladder.
  a. The chemise or outer canula, after being once  introduced into
the urethra, is to remain there and to serve to protect it.  As it must
be adapted to this canal, its  dimensions are to be increased or dimin-
ished, according to the age  of the  patient  and the peculiar  anatom-
ical  relations  of the parts.   It is  necessary  that  its walls, with
as little degree  of thickness as possible, should also  possess a great
degree of resistance, at least at its vesical extremity.  Its outer  ex-
tremity is generally provided with  a box (boite) of leather or cork,
and cut into four facettes (pans) to the  extent of an inch or two, in
order that it may be embraced by  the mandril lathe  or vice.
  b. The litholabe is one of the articles  which has undergone  the
greatest  modification ; it  is unnecessary to speak in this respect of
M. Civiale's first  instrument, which resembled the vesical quadruple
of Franco, or of  that which M.  Leroy proposed in  1822, and  which
is composed of four watch-springs, which form when they open a
double crossed  noose in the  bladder, since these instruments have  not
been adopted by  any body, not even by their inventors, and that  the
one made by M. Luckens,  a cutler of  Philadelphia, upon  the same
principle, is  no  better.   M.  Colombe  proposes a  litholabe com-
posed  of two concentric canulas, each of which is terminated by two
elastic branches united at their extremity, and which may be crossed
at a right angle around the stone when "this latter has been  "rasped.
This instrument,  which is evidently constructed  upon the same idea
as the litholabe of M. Leroy or that of M. Luckens, will have  the
same fate as the preceding ones. 
LITHOTRITY.
655
  c. It  is the forceps, properly so called, which, up to  the  present
time, has been generally relied upon.   This forceps, which is a simple
modification of the irifide canula of Sanctorius or F. de Hilden, and
of the ball extractor of A. Ferri or Andre de la Croix, is also the one
the authorship of which has given rise  to  the greatest contention.
Three elastic branches, curved  in the  form  of a hook,  and  lapping
over in such manner that  they may be closed up and reduced to the
size of the principal stem in bringing them  into their sheath, termi-
nate its vesical extremity,  while the other  has a leather cap,  but
without any pressure screw, like that of the first  canula.
  d. The litholabe, such as I have just described it, has not met with
the sanction of all lithotritists.  Many of them have specially endeav-
ored to increase the number of its  branches.   Some have given it
four, M. Amussat proposed five, and Meirieu  (Bull, de Fir., t. VII.,
p. 360—t. XII.,  p. 240)  had divided  it  into twelve.  M. Tanchou
(Ibid., t. XIX., p. 72) recommends ten.   That  of M. Recamier is
composed  of  two canulas which each contain five  branches, and
which, by turning upon each other, soon  form a forceps with from
five to ten branches.   These various modifications have been con-
trived for the common object of retaining the calculus with  greater
facility as soon as it  has been grasped, and also of not allowing its
principal fragments to make their escape from the instrument.
  e. The lithomyleur of Meirieu,  successively improved by MM.
Recamier and Tanchou, is also distinguished from  the others in this
particular, that the free extremity of all its branches is pierced with
an  eye for the passage  of a  very strong silk cord,  intended  to
approximate them and to prevent their separation, in the same way
as the cord of a  purse, and which,  in order to come to the  outside,
is made to  pass  between the two  canulas in a special groove for
that purpose.  That of M. Recamier moreover may, by the  rotation
of the two canulas, present on one of its sides a large opening to the
calculus, and then close  itself up around  the foreign  body.   In  the
apparatus of Meirieu and M. Tanchou, we again find the same pre-
caution, but under another form,  that is to  say, that one of  the
branches of the forceps which has remained in  the canula, leaves a
lateral opening for the entrance of the stone, and may be afterwards
brought to a line with the other branches by means of tractions made
upon the silk cord.
  /. M. Ashmead, of the United States,  has  presented one to  the
Academy which has four divisions, three of which are quite approxi-
mated together, while the fourth is considerably separated from them.
By  means of this  arrangement, the forceps leaves on one side all the
interval required for grasping the  largest sized stones, and on  the
other represents  a sufficiently close grillage, which is to be turned
downwards at the time of breaking up the stone, in order not to allow
of the escape of those fragments which are of considerable size.   It
would be better without doubt, if we could  be enabled  to keep the
calculus shut up until it was completely destroyed ;  but the instru-
ments proposed do not procure this advantage but at the expense of
several  others.  In multiplying  the branches  they are necessarily
weakened.   As the calculi are far from always having a regular form,
or being constantly so situated that  they may be seized  by the for- 
656
NEW ELEMENTS OF OPERATIVE SURGERY.
ceps centre to centre, there would be reason to  apprehend that one
of its numerous branches might be placed under the necessity of sus-
taining the whole effort, and  consequently that  it might  slip or be
broken.  If, as in the apparatus of Meirieu, its extremities are united
by a silk cord, the accident doubtless is less to be apprehended, while
the little  cage (cage) presents  a much greater degree of regularity;
but might not the silken thread break, and might it not  become en-
tangled in  the branches of the instrument  itself?  Are we  always
very  sure  of being enabled  to  make it  work  freely ?   Moreover,
when the litholabe is once  shut, how could we disengage the stone
from it, if the bladder should be emptied and had contracted violent-
ly ?   If the forceps  with three branches could not fulfil our intentions,
that of M. Ashmead, which while it possesses sufficient force, enables
us to  have  a grillage closer than the common forceps, might of itself,
as I conceive, be substituted for it, at least in the process of simple
perforation.  The eel-skin bladder connected by M. Deleau with one
of these  lithotritors, would not improve them any, even though we
should attach this pouch to the  extremity of  a  straight catheter, in
order to inject into  it diluted hydrochloric acid, for  the  purpose of
dissolving the calculus, as recommended by M. Zaviziano, (Alem. de
VAcad. Aled. Chir. de Naples, 1831.)
  g. Lithotritors.—A steel rod, the vesical  extremity of which only
can be susceptible  of important modifications, is charged with the
office of  acting on the stone.  In  the first instruments used by M.
Leroy, this stem was cylindrical, and  terminated in points.  In the
instruments of M. Gruthuisen, there is  one which is armed  with a
head similar to the  crown of a trephine.   This last is the one that
M. Civiale  has preferred.  It  results from  this,  that  his lithotritor
must be introduced at the internal  extremity of the forceps, and that
it can only  be withdrawn with the whole of the instrument, while the
cylindrical  drill penetrates  and comes out by the outer  extremity.
On the other hand, these drills with a head  evidently  make  a more
considerable perforation than the others.   M. Civiale, in order to ob-
tain a still greater opening, has had some constructed which  are ex-
centric, that is to  say, having their axis outside the axis of the stem.
The advantages of the drill are, that  it presents  a great degree of
solidity, acts with force and certainty,  and does not  expose to any
serious accident.  The actual objection which is made to it, is that of
giving us an opening only of three to four lines, that of requiring us
frequently to change the position of the calculus, and of repeating the
operations,  should the stone be somewhat large.
  h. Opening drills, (Forels a developpement.)—Struck with the
above mentioned imperfection, several surgeons  immediately under-
took to find a remedy for it.  M. Leroy, who was one of the first, had
constructed countersink drills (forets a fraise) and opening lances (lan-
ces a developpement.)  A drill cleft at its extremity first enabled him
to make a perforation, and afterwards to enlarge it, because in pushing
the fraise out of its canula its two branches opened from it forcibly in
consequence of their natural elasticity.  Another instrument of "the
same  character, appeared to him to be calculated to attain the object
still better.   Its  two branches  separate  apart,  from  the head of
the drill,  by retracting upon  themselves.   Finally,  M. Lerov  con- 
LITHOTRITY.
657
Btantly following out the  same idea,  has  employed  with  success a
cylindrical stem enclosing a fraise  with a double blade, which may
escape from it when we push upon it,  through  two apertures placed
near the extremity of the drill.  The double fraises of M. Civiale,
which are parted by a transverse bar, or simple head, as they retract
upon  themselves under the influence of a quick screw acting upon a
central stem, do not appear to me to be calculated to remain in prac-
tice.  M. Heurteloup, in order to obtain an excavation of  from 8 to
12 lines  in diameter, made use of a  drill with  a cylindrical head,
and pierced  on one  side, and which  at first served him as a stone
perforator, (perce-pierre.)  When he afterwards wishes to hollow out,
(evider,) excavate, and reduce the calculus into a shell, he pushes  by
means of a central stem, the base of a toothed virgule, contained in
the head of his  drill, and which immediately goes beyond its circum-
ference to the  extent of  one, two or three  lines,  while making  its
escape through the lateral aperture.
  II.  Evidement.—For calculi that are still larger, M. Heurteloup
has invented what he calls his forceps-evideur, that is to say, a cyl-
indrical drill with a jointed fraise, and which  may be parted laterally
in such manner as to make an excavation of  more than an inch in
diameter;  but a slight inspection of this  instrument will show that
we cannot place any great confidence in it and that it cannot have any
great degree of power.   M. Amussat  has also occupied himself with
the subject of evidement.  His drill, which is based on the principle
of one of those of M. Leroy, is composed  of a central head and two
lateral portions.  When we have perforated the calculus with the in-
strument closed, its stem is withdrawn by means  of a screw which is
between the two fraises, and which separates them so as to allow-of
our making a considerable enlargement to the excavation.   This is
the drill which  two cutlers, MM. Greling and Charriere,  have suc-
cessively modified.   The cylindrical drills, having a virgule which is
separated at  the distance of three  to four  lines from the axis of  the
principal stem, like those which  have been proposed by MM. Tan-
chou and Pecchioli, appear in  my judgment  to be  less commodious.
I  would say the same of the  fraises with  triangular points and with
wings like a windmill, like those of M.  Pravaz,  and also of that
which M. Rigal recommends with a sheathed  drill.  This last men-
tioned surgeon also proposes to obtain another result, different from
any proposed by those who have preceded  him.  When the per-
foration is effected,  a quick screw withdraws  the  fraise  between
the  two blades  which constitute its sheath, separates  them and fixes
them  firmly in the centre of the calculus, which is thus found as it
were impnled upon the drill in such manner as to be susceptible of
being broken up against the inner side of the branches of the litholabe.
M. Rigal considers, on the other hand, that in  separating the forceps
from  its  instrument,  we  would be enabled  to break up  the stone
into splinters by an excentric effort.   In this respect  he follows  out
the views of M. Civiale, who proposes a similar means after lithoto-
my, when the stone is too large to be  extracted  without danger; or
those  of M. Leroy, who says the same of calculi of the urethra; an
idea which Fischer  (Theses de Haller,  t.  II.,  Fr.  transl.) and some
authors of the seventeenth century had also entertained.  It is doubt-
  vol. hi.                    83 
658
NEW ELEMENTS OF OPERATIVE  SURGERY.
ful  if lithotrity by  excentric rupture will ever become a general
method, whether we effect it  by the action of sheathed driF.s, or
divergent blades, or by means of percussion upon the free extremity
of the lithotritic  instrument.  As  to evidement in itself, the fraise
with a double elastic branch, as proposed by M. Leroy, and as it
has been  improved  by MM.  Amussat  and Charriere,  is the one
which has most solidity and is most certain of effecting this object,
though the mandrin with a virgule, as contrived by M. Heurteloup',
and the  developing drill  of M. Pecchioli, might  replace  them in
certain cases.
  III.  Concentric Crushing, (Broiement.)—In place of opening the
stone  at its centre, and of hollowing it out from  the interior to the
exterior,  Meirieu conceived the  idea of reducing  it into powder, by
acting from its surface to its central portion, by means of a cylindri-
cal  drill provided with two  virgules with a lateral development, and
which could  be  separated at pleasure so as to  form with the stem
a sort of clover  leaf.   MM. Recamier and Tanchou have followed
out the same  principle,  and all the efforts that have been made have
had no other object  than that of rendering its application  more easy
by  improving either the litholabe or  the lithotritor.   It  cannot
be  denied that  this way  of breaking up the stone is  more rapid
than the  preceding; that  we may by this means  possibly pulverize
a large sized calculus  at  a single sitting ; that it protects us from
the inconveniences  of  breaking the stone into fragments, and en-
ables  us to hold it grasped to the end  of the operation, without be-
ing under the necessity of letting go our hold to resume it at another
time.   But the drills and  the fraises which we are obliged  to make
use of are necessarily weak, and may bend or break.  The separa-
tion of the virgules may lead us to apprehend that they may become
entangled between the  branches of the forceps, if  we are compelled
to approximate them a little too near  the  sheath.   We have, more-
over,  all  the inconveniences which I have pointed out in speakino- of
the litholabe with multiplied branches supported by a silk cord. The
essays of  Meirieu and those of M. Recamier, were only made upon
the dead  body.   M. Tanchou, (Lancette Frang., t. V., p. 232,) like
M.  Pamard, (Transact. Mid.,t. VII., p. 306,) went  farther.  His ap-
paratus enabled him in a patient to break up at a single sitting, a cal-
culus  of  a certain size.  On the other hand he permitted me to wit-
ness essays which he had the goodness to  make in an adult man whom
I had  sent to  him for this purpose.   The stone could not be grasped,
and I supposed that lithotomy would be necessary.  We then ascer-
tained that the foreign body was of too  large a size to allow of any
method of breaking it up to succeed.  It would  not, therefore be
just to deny to the apparatus of M. Tanchou the capability of being
applied with  advantage.   The  breaking down the stone from  the
circumference to the centre by means of the  inner surface  of  the
branches  of the  litholabe, against which  the  calculus which is im-
paled  by  the  sheathed drill is  made to  turn, as had been proposed
by  M. Rigal,  (Bull de Fer.,t. IX., p. 67-t. XXL, p. 104,) has some-
thing very ingenious in it, and at first sight even specious, but  the
slightest  reflection  also shows  immediately that  such a suggestion
must be inapplicable.                                     && 
LITHOTRITY.
659
  IV.   Crushing the stone,  (Ecrasement,)  is one of the means
which the ancients especially directed their  attention  to.  Thus it
was the  ecrasement,  and not the breaking up (broiement) of  the
stone which was recommended by Acaravius, and which F. de Hil-
den and  many others  made use of.  Ecrasement  was  also the me-
thod which Amussat used in 1822.  This mode of breaking up cal-
culi, for  a time forgotten, appears to be upon the point of contesting
the palm with broiement, properly so called.   Among those who pro-
pose this mode, there  are some who adopt  it only as an accessory
method, for the small  calculi, or for the fragments which result from
perforation and evidement; while others  endeavor to bring it into
repute as a general method.   In the first case it has almost always
been combined with the other processes.  When M. Civaile, for  ex-
ample, finds that he has seized a calculus of only 3 or 4 lines dimen-
sions, he compresses  it forcibly between the  branches  of his litho-
labe, and afterwards crushes it by  pushing  the  head of the lithotri-
tor by means of  the  palm of his  right  hand.  He  proceeds in  the
same manner with fragments that are somewhat  large,  and  with
all  those particles  which are of too considerable size to be extract-
ed  entire through the  urethra.   M. Civiale had also  contrived a for-
ceps with two  branches, which could glide  upon each  other, and
crush the small stones by a movement  backwards and  forwards,
nearly in the same way as with the instrument of  M. Amussat.   M.
Rigal has modified this instrument  in  making it act  by means of a
quick screw,  while dispensing with the movement  backwards and
forwards.  M. Colombat endeavored to  make it more easy to man-
age by adding volants to it, to give it  motion, and by fixing a small
chain to the extremity of its  branches, in  order  that  these, should
they be broken, might be brought out without danger.  The forceps,
which in this  respect  has attracted most attention, is the one that
M.  Heurteloup  has  delineated under the  title of  brisecoque.   Its
branches rub against  each other, and  by means of  an  encliquetage
we are enabled to make  these branches re-enter  into  the external
canula, with such degree of force, that they scatter into splinters  the
hardest and most  unyielding  calculi.  A forceps  constructed upon
nearly the same principles,  and which has three  instead of two
branches, was  contrived in 1829  by M. Rigaud, (These, No. 276,
Paris, 1831.)   This species of grugeoire can seize calculi of an inch
in diameter in the same manner as  the ordinary litholabe.  The  ad-
dition of an encliquetage, enables us also to give motion to its three
branches, and to execute on the three  corresponding  points of  the
stone such frictions as will reduce  it into a fine powder, and allow
us to grind it up  and destroy  it completely before letting go   our
hold of it.  It is a species of brisecoque or stone-breaker, which does
not possess as much force as  that of M. Heurteloup, but which  has
the advantage of breaking down the calculus by friction instead of
splitting it into fragments.  A  skilful  cutler, M. Sirhenry,  has con-
structed  another forceps,  which is equally well calculated for  the
ecrasement of calculi.  Its three branches, which  are  destitute  of
hooks, present on their inner side a dentated crest, which is to be  ap-
plied upon the foreign body.  It is'to be introduced  into the bladder
in the same  way as  an ordinary litholabe.  After  the calculus is 
 660          NEW ELEMENTS OF OPERATIVE  SURGERY.

 once seized, we make the  branches re-enter into the  external can-
 ula bv means  of a quick screw, and this screw acts with so great a
 degre"e of power, that even siliceous and flinty stones are incapable
 of making resistance to it.  An essav which  was made with it at
 the Hotel Dieu,  was followed by the breaking of one of its branches,
 and this,  in fact, is  the danger that we would appear  to have to
 apprehend from it at first  view ; but  M. Sirhenry  replies  to this,
 that the instrument which  was made use of, was not  designed for
 such large calculi, and that he had foreseen the accident in question.
 It is at least true that the instrument which he  has shown  to  me,
 and  which the hardest  calculi are incapable of resisting, possesses so
 great a degree of strength, that it would seem absolutely impossible
 to break  it.   An  objection  which some  persons have also  made
 against it, is that of exposing to the risk of wounding the bladder by
 means of  the splinters of stone which the instrument has a tendency
 to throw off to a considerable distance.  This  danger  is evidently
 imaginary.  A stone which was thus  broken up  between my two
 hands did not occasion me any sensation of pain, and  inasmuch as
 we act in  the bladder full of fluid, there can  in this  respect  be  no-
 thing in reality to apprehend.
  V. Of these four modes of breaking up calculi,  there is no one of
 them which deserves to be  adopted to the exclusion of the others, or
 which should be absolutely  proscribed.  The  perforation  of a stone
of from 5 to 6  lines in diameter, may be advantageously combined
 with ecrasement.  If the fraise has  made an opening  of four lines,
for example, we may, after  having drawn it back  to  near its sheath,
bring the litholabe forcibly backwards, and make use of it then as a
 brisecoque.  Instead of this process we may,  if the exploring means
we have made use of have enabled  us to ascertain with certainty
that  the calculus is  of but  little  size, employ the grugeoire of M.
Heurteloup, or one of the forceps, either that with the  encliquetage
or with the volant, or  the  quick screw, which  have been described
above.  When the stone exceeds ten lines or an inch, the most  suit-
able process will then  be  successively, perforation, then evidement,
and  finally ecrasement.  By  means  of the  forceps  of M. Rigaud,
we might  succeed without any very great  degree of difficulty, in
 breaking up calculi  of  from 8  to 12 lines  in  diameter;  which could
be effected, as  I conceive, with still greater  facility, by  means of M.
Sirhenry's  instrument.   A  remark which should  not escape  the at-
tention of the practitioner is this, that by means of the new ecrase-
ment forceps, which  will be mentioned "farther on, the  operation is
found at the present day to be surprisingly simplified, since  it is no
longer necessary, with these, to have recourse to  drills, fraises  sup-
porting apparatus,  &c.; so much so that they have succeeded in
giving general reputation to lithotrity.
  VI. Accessory apparatus.—Whatever may be the lithotritic appa-
ratus selected, the means by which it is put in operation  deserves also
the  attention of the  surgeon.   The mechanism  of stone-breakers
bnsecoques, saxifrages and grugeoires having been  everywhere based
upon the system of quick screws, double levers,  encliquetaees  or en
grenage, constitutes a part  of the principal instrument,  and does not
requiie to  be  separately described.   This  remark does not apply 
LITHOTRITY.
661
to broiement, properly so called, whether by perforation, evidement
or concentric pulverization.  Two kinds of springs, then, become in-
dispensable : 1st, to steady the litholabe firmly ; 2d, to give action to
the lithotritor.
   a. In regard to the first, the chevalet, which is  a sort of mandril
lathe, as proposed by M. Leroy, after Ducamp, and as  modified by
MM. Civiale, Rigal, &c, has  been  generally adopted.  Some per-
sons, however, have proposed  to  substitute  for it an ebony vice
(etau en ebene) with one  or two grips; others have directed  much
attention to  the manner of steadying at the same time both the in-
struments  and the patient. From  hence comes  those  beds, which
are or are not furnished with  supports, as proposed by MM. Leroy,
Heurteloup,  Tanchou and Rigal, anil  which are  evidently useless.
The bare  idea of metallic supports intended to be kept immovable
on the  foot  of the  operating table,  like the one proposed  by M.
Charriere, or the  suggestion  of mechanical beds  (lits mecaniques),
like that of  M. Heurteloup, is in itself revolting.   Let  us imagine,
for example, a forceps, or any kind  of lithotritor  manceuvering  in
the  bladder  of a living man,  while a solid bar of iron implanted in
the  table fixes them securely outside, and we shall see  whether the
slightest irregular or unexpected movement on  the part  of the pa-
tient, is not calculated to make us  tremble for the consequences.
However  ingeniously constructed these dead forces may be, they
should  be  rejected,  and  we must  depend for  accessory  means
upon the hands of intelligent assistants, or upon the surgeon him-
self.  M. Amussat, by pressing with his chest  against the  lithotritor,
by means of a point d'appui interposed, in such manner as to be en-
abled to hold the  litholabe with the left hand at the same time, that
with the right  hand he  is enabled to turn  the drill with  a wooden
handle,  in the manner  of a  centre-bit wimble   (vilebrequin), has
none of these dangers to dread; but it acts  with  less force  than
when we make use  of  the mandril lathe, and fatigues  much more,
so that all things being properly  considered, the  chevalet is still
the instrument which is best adapted to the object in view.
  b. In the action of the drill there are  two forces to  be  directed,
that which presses upon its outer extremity to keep it applied against
the stone, and  that which compels  it  to turn upon its axis.  Those
who have  supposed  that  they could  substitute for the  first, either
the thumb, forepart of the chest or the knee, are evidently under
an error, unless, in fact, they  can discover a better arranged sys-
tem  of mechanism than  that  of the wheels, villebrequins and  mani-
velles hitherto employed.  The cork-screw spring, enclosed in the
movable poupee  of the mandril,  certainly leaves much room for
improvement.  Nevertheless, I see  nothing which  can  be advanta-
geously substituted for  it, so  long  as the  bow  (archet) shall con-
tinue to  be preferred as the rotating  power.   The rings, volants
and  manivelles, which  at first view would appear to  be sufficient
to supply the rotating power, are  not sufficiently extended in  their
action, nor do not sufficiently favor the forces put into play, nor the
movements made use of, to enable  us  to derive any great advantage
from them.   The engrenage wheels placed underneath,  as was pro-
posed by M. Leroy, or  upon the  side, as in  the apparatus of M 
662
NEW ELEMENTS OF . OPERATIVE  SURGERY.
 Pravaz, whether they act upon a pignon, parallel to the axis of the
 litholabe, or catch into a dentated conical and circular pignon, impart
 to the drill as rapid a movement as can be desired ;  but there still re-
 mains to be discovered a means of making pressure upon its extremity
 at the same time with a sufficient degree of force.   As to the mechan-
 ism of the bow, it is the same in lithotrity as  in the mechanic arts from
 which it has been  thought proper  to borrow it.  Until  the wheels
 can  be substituted  for "it, prudence  requires that we should con-
 tinue to make use  of it, and the  useful results which  it has already
 procured,  enable us after all to employ it with more confidence than
 any  other  means designed for the  same object.  All these contri-
 vances, however, become unnecessary in the apparatus of new for-
 ceps and nooses.
   VII. The general operative manual.—Before proceeding to litho-
 trity, there are some special precautions to be observed.   Upon the
 supposition that the urethra has been diseased, we should in the first
 place restore it to its natural dimensions, and impart to it its original
 dilatability.   Even  though this canal should be  sufficiently large  to
 give free passage to the instruments, it may be advantageousto ha-
 bituate it  during several days to the action of  flexible bougies, or
 sounds, in order to blunt its sensibility, and  to accustom it to the pre-
 sence of foreign  bodies.   It is advisable also for the  same reason,  to
 throw up some injections into the bladder, in order to diminish its ir-
 ritability, and that it may be distended with more facility at the time
 of the operation.  Although these preparatives are not indispensable,
 they cannot however be absolutely omitted, but in a very small num-
 ber of cases.
  a.  Position of the patient.—In  private practice we  may  lay the
 patient on his back on the edge of the bed, with the pelvis supported
 upon a cushion  which is somewhat hard, the feet resting upon stools,
 and the head moderately flexed upon the chest.   At one's own office,
 or in a public establishment, we may place him upon a narrow bed,
 of convenient height, in such  manner that  his legs may go beyond
 the foot of the bed, and be supported in the manner just described. In
this position there is no need of his  being tied or bound down ; the
 posterior wall of the bladder having become its  lower wall, enables
the calculus to become removed to a greater distance from  the  ure-
thra, and to present itself, so to speak, of its own accord, to the litho-
labe.  It is moreover easy to modify this according to necessity, either
by a greater elevation of the pelvis, if the stone has a tendency to
remain in the bas fond, or by diminishing  the thickness of the cush-
ion, when we apprehend the contrary; which resource is not afford-
ed us to the same extent by the  employment  of lithotritic beds or
tables.
  b  Injections.-A first stage  of  the operation consists in filling the
 bladder with tepid water, or some emollient decoction.  Unles? this
injection were made, we could  not give free  play to the litholabe or
hthotntor   The stone could not always be seized, and the bladder
might be frequently pinched up by the instrument.  This injection is
effected by means of an ordinary catheter  and hydrocele syrinee,
 with more  certainty and with less  embarrassment than with  blad-
ders, or bottles of caoutchouc, or by the canula or sheath of the Ptho- 
LITHOTRITY.
663
 labe.  After the silver  catheter is  once introduced, it  serves at the
 same time to ascertain again the presence of the calculus.  An assis-
 tant then immediately takes charge of it in order that the surgeon
 may adapt the syringe of the syphon to it, and throw  up the liquid.
 When from 8 to 12 ounces of the injection have been thrown up, or
 what is better still, as soon as the patient has a somewhat urgent de-
 sire to urinate, the catheter is to be withdrawn in order  that the litho-
 tritic apparatus may immediately be substituted  in its place, and be-
 fore the injection has time to be discharged.
   c. Introduction of the forceps.—The drill, provided  with its drill
 box to receive the bow, being glided into the canula of the forceps,
 and the litholabe, furnished with a  box at  its outer extremity, being
 introduced in its turn into the common sheath in such manner that its
 branches accurately closed upon the grooves of the head of the litho-
 tritor, represent an olive head which is to be lubricated with ointment,
 are then introduced united  together into a single piece, in the same
 manner as a sound into the urethra.  For this purpose, the operator
 placed on the right of the patient, grasps the penis with  his left hand,
 in the same manner as in  ordinary  catheterism, and  raises it slightly
 upwards ; presents to it perpendicularly with his right  hand, the in-
 strument well oiled or greased ; gently inserts it by  slight  move-
 ments of rotation into the meatus urinarius; soon arrives at the bulb ;
 stops for a moment; gently but firmly  depresses his hand in order
 to pass under the symphysis and through the membranous and pros-
 tatic portions of the urethra, and in this manner arrives beyond the
 neck of the bladder.
  d. To find the stone.—Before opening the litholabe, we look for
 the calculus by passing  around, by  means of gentle vibratory  move-
 ments, the olive of the metallic tube, which is still shut up: 1st, from'
 before backwards, upon the middle portion of the bas fond and  pos-
 terior wall of the bladder; 2nd, from behind forwards, in order in
 returning to complete the circle, either on the right or  the left side;
 3d, from before backwards a second time, returning by the opposite
 side in order to come back on  the middle portion, where the stone
 may have  again fallen, and then transversely in such manner as to
 leave no  point on the  vesical wall, which  has  not  in  reality been
 touched.  If, notwithstanding this  minute research, we encounter
 nothing, it would be better to defer the operation than  to persist in
 continuing the exploration.  We  ought not, however, to give up
 until after having sufficiently varied the posture of the patient, and
 after having  thoroughly satisfied ourselves that no cavity or natural
depression has been overlooked.
  e. To open  the forceps.—When the seat  of  the  stone  has been
proximately determined, the operator takes in his right  hand the ex-
tremity of the litholabe, which he holds immovable, and with his left
hand draws towards him the external canula, as if with  the intention
of extracting it from the urethra, and in this manner enables the forceps
to open itself by leaving it to the natural elasticity of  its branches.
 In this manner the bladder incurs much less risk, than if he made the
 litholabe glide forwards without deranging its sheath for the purpose
of protecting the urethra, the entrance into which latter, moreover, 
664
NEW ELEMENTS OF OPERATIVE  SURGERY.
 remains perfectly filled up by the gorge of the triploide which opens
 itself in the bladder.
   /. The finding of the calculus  and the grasping of it is frequently
 a more difficult matter than is supposed, so much the more so as it is
 not sufficient alone that we should feel  it in  order to know exactly
 where it is.   To discover it, therefore, exacts the greatest degree of
 attention.   The  difficulty is  to know whether we  touch it:  1st. by
 the convexity of one or both the  lower hooks of the instrument; 2nd,
 by the middle portion of one of its branches, either on their inside or
 outside, and in this case whether  it is to the right or the left; and 3d,
 by the lower surface of these same branches near the prostate, &c.  In
 this respect the following rules should not be neglected.  If by ma-
 king the forceps vibrate, we perceive that it  strikes  upon a foreign
 body and gives the sensation of a double shock, the calculus  is below
 its two branches and  behind  the prostate.  If one of the branches
 descends lower than the other while turning on its axis, and  a simple
 shock only is produced, the calculus  will then be found on the most
 elevated part. If it is in  front, and  the two hooks pushed in succes-
 sion, and  not simultaneously, alike feel  it, we  may consider  that the
 calculus lies in the interval between them.  If one of them only re-
 cognizes it,  it should be on one side.   We ascertain whether it is on
 the right or left by keeping one hook immovable, while we make the
 other gently  advance. Admitting in place  of this, that it  may  be
 outside of the left branch itself; if, in taking the other for a point
 d'appui, we raise up and  depress it by movements of rotation de-
 scribing the arc  of a circle, it will  not fail to be soon  recognized,
 while  the same movements repeated on the  opposite side will dis-
 cover nothing.  A transverse movement of slight extent to the right
'and then to  the left, will in the same manner inform us if the stone is
 in the interior of  the litholabe, or nearer to one of its branches than
 the other, or in the centre.  Finally, these various movements com-
 bined with some  degree of skill, will not permit us  to hesitate for
 any length of time upon its actual situation, provided the surgeon has
 taken the precaution to place two of its hooks below and upon  the
 same line.   Having arrived to this point there can be no longer any
 great difficulty in embracing  the calculus in  the open space of the
 instrument, and consequently none in grasping it.  In order  not to
 derange the relations of the objects, we again take the free extremity
 of the forceps and  raise it slightly upwards with  the  right hand, in
 order that its branches may continue to rest against the bas fond'of
 the bladder, after which we push over it again the sheath or external
 canula  by seizing the leather box  of this last with  the left hand.
 It is advisable, moreover, before doing this,  to impart to the drill
 certain movements backwards and forwards in the tube, and between
 the divisions of the litholabe, until the fraise has actually touched the
 stone.   By an effort made in  the contrary direction upon the sheath
 and upon the stone, we finally secure this last, after which we have
 nothing more to do than to attack it with the lithotritor.
  g.  To apply the mandril lathe  and the bow.—This is  the moment
 for placing the supports and the moving  powers.   A pressure screw
 m the first place,  prevents the two instruments when closed from re'
 opening.  A mortice on the head of the mandril then embraces  ia 
LITHOTRITY.
665
 seizing it  below, the quadrilateral  extremity, having lateral arrests.
 of the sheath in front of its box, while a pressure screw immediately
 secures them in  this position.  The small cap (cuvette) of the spiral
 spring, supported by the poupee of the mandril, is then applied upon
 the queue  of the drill.   We push forward  this poupee with a force
 proportionate  to the action which we intend to exercise upon  the
 stone and  drill.  This in its turn is to  be arrested by a turn of the
 screw.  If the pressure of the spring appears  to  be too strong, a
 fourth screw enables us to  suspend it or to resume it at pleasure.  The
 apparatus  is then prepared.  An assistant  with  his face  turned to-
 wards the pelvis, and placed between the legs or on the right of the
 patient, takes charge of it  and  seizes  its handle with  his right hand
 and its angular part with his left hand.  The operator takes the cord
 detached from the hook of the bow,  passes it around the drill box,
 which has previously been adjusted upon the drill, and reapplies its
 buckle upon  the extremity of the  elastic bow, from which he had
 momentarily separated  it; it being well understood that this  cord,
 while it should  be sufficiently slender, should possess a great degree
 of force, and work with the least degree of friction possible.
   b. Broiement.—This  being arranged, the  surgeon, who is to be al-
 ways placed on the right, holds the instrument firmly in his left hand
 between the penis and  the head of the chevalet, while with his right
 hand he puts the bow into  action, taking care to incline  its  motion
 forward, and to unite pressure against the stone with rotation, should
 the spring  not appear to be sufficient.   The drill  box moreover has
 been fixed  in such manner  as to  strike against the drawing box of
 the litholabe, before the head of the drill can reach the vesical extrem-
 ity of the litholabe, and  go beyond the circle of the forceps.   This
 first perforation  having been terminated, we withdraw the poupee
 of the mandril backwards, in order to bring the drill towards  us.
 If the  stone is small and friable, we endeavor to crush it by acting
 forcibly  in an opposite direction  on the  two  cork  boxes, before
 loosing our hold upon  it.  In the  contrary  case we  open the for-
 ceps gently, and then by small taps on its  free extremity,  endeavor
 to move  the calculus and change its  position; a change  which we
 may assure ourselves of, and  may favor  or even accomplish,  by
 means of the drill directed with  the  right  hand.  If we  cannot in
 any way effect this, we let go  the  stone altogether, in order to re-
 grasp it in  the same manner as  if it had escaped in spite  of the  in-
 tention of the operator.  Under the apprehension that it may pre-
 sent itself exactly at the same diameters, which  rarely happens, we
 push the  head of the drill  against it,  and displace this drill again,
 should it again fall into the  same hole, nor set it in movement a sec-
ond time by means of the bow, except  it shall meet a solid portion
of the body which is to be  destroyed.   The employment of develop-
ing drills, and  fraises with a virgule or with files, or with  simple
or double wings, is subjected to the  same rules, whether we  have
recourse to them at first, or only after the first  perforation.   In the
first case they are to be separated apart  in  such  manner  that they
may turn freely behind  the calculus, without touching the  inner sur-
face of the branches of the litholabe,  and that the central head may
seive as an axis to the lateral wings  while they  are  acting on the
  vol. ra.                     84 
666
NEW ELEMENTS OF OPERATIVE SURGERY.
stone   Ir the second case, they are  to  be opened  only by degrees
and in the interior itself of the first  perforation.   It is under  such
circumstances that  the  name  of echoppeur and evideur may be lit-
erally applied to them, inasmuch as  their effect is  to transform the
stone into a shell, and to dig out a '.onical cavity in it, the apex of
which is placed posteriorly.  The spherical stones,  which  are some-
what large, and which are [accurately] grasped centre to centre, are
the best adapted to these drills ; those stones which are elongated, and
which are seized only by one of their projections or at  their  side,
and  which leave a void on one  side between the branches of the
forceps, render the action of the drills difficult and  sometimes  dan-
gerous,  in consequence of  the unequal  resistance  which   they
encounter while  turning.   The apparatus of M.  Tanchou, though
more ingenious, is not altogether exempt from this inconvenience,
and in my opinion it would be advisable in such cases to confine our-
selves to the simple percussion (taraudage,) combined with the ecrase-
ment.   When the stone is  actually broken  up, or the patient too
much fatigued, that  is to say, after the  expiration of 5, 8, 10, or at
most 12 minutes, it is  advisable to terminate  the sitting.   The  bow
is to be  then removed.   We loosen all the pressure  screws in order
to remove the  chevalet  and to withdraw the drill  in proportion  as
we shut up the forceps.  When a fragment has become arrested be-
tween  its branches, we should,  if it is not too large,  withdraw it
with the rest of the  instrument;  but  should  there  be ever  so  little
reason to apprehend that it may injure the urethra, it is better to let
go our hold upon it or make it  fall again into the bladder by pushing
it back by means of the lithotritor.  The remains of the injection and
urine which the patient generally feels a desire to discharge immedi-
ately after, almost always bring away portions of the calculi, and a
greater  or less quantity of powder resulting from the broiement, and
wihch are a  proof in  regard to the patient, that the operation has
been attended with as much  success as it was possible.   A  bath
is to be  prescribed immediately, or  during the course of the  eve-
ning.  In ordinary cases, the attentions required, consist of nothing
more than those  which are demanded during  any state of convales-
cence, or for valetudinarians in general.   We  recommence at the
expiration of 2, 3, 4, or 5 days, according as  the system  has  been
more or less disturbed by the first essay, and always with  the  same
precautions,  and so  on consecutively until  there is no longer  any
vestige  of calculus  in  the  bladder.  One or  two explorations by
means of a  simple  sound at intervals  of a few days, are also re-
quisite in order  that  we may obtain satisfactory evidence on this
point, and should  not on any account be neglected.
  B.  Curvilinear method.—It  is a  remarkable circumstance, that
the breaking up  of  a stone could  not  be accomplished  until  at
the epoch when it was demonstrated  that it was practicable to intro-
duce straight instruments into the bladder.   To place the practica-
bility of this process beyond dispute, even grave anatomical errors
were adduced in support of it;  and  now, when there is  no longer
any  doubt with any body in respect to both these  circumstances, it
i» found that curved instruments enable us full as well as  those  that 
LITHOTRITY.
667
 are straight, to attain  the  object  which  had  been  so  long de-
 sired !
   I.  The  mandrin file, employed by Major Martin, was introduced
 through a  curved catheter.  The instrument of M. Eldgerton  also
 had the usual curvature  of sounds, as likewise had the first lithopri-
 onne forceps of M. Leroy.  The most difficult point in the ancient
 system was to make the  lithotritic instrument turn on its axis.  Now
 M.  Pravaz,  in  1828, succeeded  in giving the same facility to the
 movements of the drill or fraise, in a curved as in a straight catheter;
 for that purpose he  transformed  the inner fourth of his perforator
 into an articulated stem or small chain, which was full as  strong, how-
 ever, as the  stems which were of a purely cylindrical form and of
 one single piece. Nevertheless, his  instrument, which was curved
 into a  very  elongated arc,  did not  yet  possess all the advantages
 which  it was desirable to obtain  from it, and  the author ultimately
 gave to it a curvature similar to that of ordinary sounds, that is to
 say, a curvature which comprised only the vesical fourth.  M.  Pra-
 vaz did not succeed with this instrument, though he applied it once
 on the living subject in one of the hospitals of Paris.   But the  fail-
 ure in  this case may be attributed  to  the want  of practice, to the
 indocility of the patient,  who was a child, and especially to the pecu-
 liar character of the calculus.  It is  difficult in fact to conceive why
 his apparatus, which differs  from the others  only in the direction of
 its principal portions, should not be capable of effecting  the same re-
 sults.   I would  even remark that it ought  to be introduced  with
 greater facility and should produce less annoyance upon the urethra.
 M. Leroy has shown me one in  every respect similar  in regard to
 the arrangement of the chain and  drill, and the curvature of which is
 analogous to that of ordinary sounds, but which he intended to modify
 still farther ;  this instrument however has this remarkable feature in it,
 that the third branch of  the  litholabe is fixed and constitutes a part
 of the conducting canula.  The  instrument  of M. Pravaz,  as  well
 as that of M. Leroy, enables us to make use of perforation, evidement
 and  concentric  broiement, in the same way as the  straight instru-
 ments, but their form is much more applicable still to ecrasement.
   II. MM. Weiss and Rigal have also  given a slight curvature to
 their encliquetage or friction forceps, and the species of noose used
 by .17.  Jacobson is  also  curved.  This last  instrument is  compo-
 sed of an external canula like the others, then of a steel cylindrical
 stem which perfectly fills it up,  and  prolongs it to the distance of
 three inches in the direction  of the bladder, which stem  is formed of
 two halves jointed at  their extremity, one placed above and the other
 below, in such manner that the   lower one being  pushed forwards,
separates itself from the  upper one  which  is fixed, and forms, by
means of two or three hinge-joints, a  noose which is capable of em-
bracing a calculus of from 12 to 15 or 18 lines in diameter.  A quick
screw  is placed  on its free extremity and enables us to replace it in
its original position.   The one which  was proposed by the Danish
 surgeon had  only two joints in its lower branch.   Dupuytren  con-
 sidered  that  it would be  better  to give  it three, in order that  the
 noose might be  more uniform and more rounded.  It is to be intro-
 duced shut up, into  the bladder.   In pushing it afterwards upon its 
668
NEW ELEMENTS OF OPERATIVE  SURGERY
 outer extremity, its  lower half  separates itself  little by little.  A
 void is made between it and the other half, which void is increased
 at pleasure, and the extent of which is ascertained by figures placed
 outside of the  nut.   The calculus  becomes lodged in this void or
 noose.   When it is accurately embraced, we act on the quick screw,
 as if for the  purpose of isolating it and shutting up the instrument by
 the approximation of its two branches.  Nothing is more simple than
 an apparatus of this kind, nor should anything be more easy than the
 operation itself, which in this manner is relieved of the necessity of
 supports, containing means, &c.  Nor have we even to fear here the
 breaking of the instrument, for its joints would enable us to extract
 its broken portions without a'ny danger.  All that may be said is that
 from having  only two branches, it  may not be enabled to seize the
 calculi with  as much  facility as  the others do, and that from  being
 confined to the crushing merely of the stone, we are obliged to seize
 hold of all its fragments separately.  I will add that the detritus of
 the stone, which sometimes remains attached to the inner surface of its
 branches, is also  calculated to render their approximation difficult.
 Dupuytren, who put it to the test on living  man, was very well satis-
 fied with it, and was enabled in four or five sittings to destroy com-
 pletely a calculus of very large size ; I have also made use of it  with
 the same advantage in many patients ; so that whether it be consid-
 ered in the condition in which it now is, after the improvements made
 upon it by MM. Leroy, Segalas, Thomas, Pasquier and Charriere, or
 after it shall have undergone certain modifications of which it appears
 to me to be still susceptible, this instrument will make excentric broie-
 ment by perforation or evidement a matter hereafter of much less
 importance, in addition to the fact that  it  has already disproved the
 necessity of straight instruments.
   III. M. Segalas, in  adopting the curved  lithotritor, also deemed it
 advisable  to modify it, in using it upon a patient who could not  sup-
 port the straight sounds.  The improvements of this  surgeon relate
 chiefly to the stem of the perforator, which in  his apparatus, instead
 of having an articulated chain, is formed of metallic wires united in a
 bundle ; and also have reference to the means of bringing to the out-
 side and  without danger, the fragments of  the litholabe, should it be
 broken in the bladder; but I cannot see in these improvements  any
 other than a very slight  alteration, together with unnecessary com-
 plications.
   IV. New processes.—M.  Heurteloup, going back  to the ideas of
 the monk  of Citeaux, has proposed a curved instrument which opens
 in the manner of a shoemaker's podometer, and which, after  having
 firmly embraced or secured  the stone between its two branches  en-
 ables us  to break it and to reduce it into fragments, by mean's of
 strokes with  a  hammer made upon the extremity of its movable or
 upper branch.  This apparatus has effected an absolute revolution
 in lithotrity, and to such extent, that at the present time no other instru-
 ment scarcely is any  longer recommended.  In place of the original
percussor of M. Heurteloup, surgical practice at the present day has at
 its disposition the percussion and compression forceps of M. Touzet
 the same instrument modified by MM.  Leroy and Charriere, the  dy-
 namometric percussor of M. Benique, the screw stone-breaker of M. 
LITHOTRITY.
669
 Siihenry, the pressure and percussion stone-breaker of M. Amussat,
 a similar instrument of M. Clot-Bey, the percussion stone-breaker of
 M. Costello,  that of M. Lestrange, the excentric screw stone-breaker
 of M. Charriere, the stone-breaker with a central screw or volant of
 M. Segalas,  that of M. Civiale with rings, that of M. Leroy of funnel
 shape, the transverse stone-breakers of M. Amussat, those of M. Ban-
 cal and M. Bevenuti with handles, and better than all these the  pig-
 non stone-breaker, such as it has been improved by M. Charriere.
 These instruments, which may be manipulated with as much facility
 as a shoemaker's podometer, and which appear to have all derived their
 origin from that of Stodard, that of M. Hodgson, or that of M. Retore,
 (Leroy, Journ. Esculap., t. I., p. 3; Hist, de la Lithot.,  Paris, 1839,
 in 8vo. fig.,)  or the forceps of Weiss, or the catheter proposed by me
 in 1827, or the double catheter of Cleland, (Bibl. de Planque, t. X.,
 p. 398, in 4to.,) render the  broiement much more secure, simple, and
 prompt, than by the ancient method.  Their free extremity being
 armed with  transverse pieces, handles, (poignees,)  plates, buttons,
 screws, volants, nuts, heads, or pignons, enable us to act upon the
 calculus either by percussion or by pressure, with as little or as much
 force as  we  may desire.  Moreover, as they possess a  large open-
 ing at the other extremity upon the  inferior or fixed branch, an open-
 ing which in  the forceps of M. Saas the upper or movable branch may
 go  beyond posteriorly, they cannot become choked up with  frag-
 ments or gravel.   Constituting in their ensemble instruments that are
 sufficiently slender, though very  solid, they give much  less annoy-
 ance to the organs than the other litholabes.
  a. Operative process.—The patient should be placed and arranged
 in the same way as has been described above.  The forceps is to be
 introduced, shut up, and according to the usual  rules of catheterism.
 The surgeon  having introduced it to the bottom of the bladder, and
 made use of  it to ascertain again the presence of the stone, opens it
 by drawing upon its movable branch with his right hand, while with
 his  left hand near the penis he holds the other branch fixed.  He
 then makes   it describe the movement  of  the  quarter  of a circle,
 which quickly brings its convexity upon the middle portion  or  side
 of the bas fond of the bladder.  By pushing the branches of the for-
 ceps towards each other, it is soon ascertained if the stone is grasped.
 In the contrary case, the same  movement is  to be  repeated, or we
 incline the branches or point of the instrument to the right or left, or
 downwards or backwards, in such manner  as to  seize the calculus
 firmly.  As soon as it is well  embraced, we  commence with break-
 ing it up.  The remainder of the manipulation then varies according
 as we adopt percussion, ecrasement, or simple pressure.
  b.  Percussion.—If we propose to break up  the  calculus by per-
 cussion, we fix the instrument by means of one of the supports men-
 tioned, or with the left hand ;  with a small hammer  made expressly
for this purpose, and held in the other hand, we make rapid strokes
 upon the  button, head,  or plate of the litholabe, with a force propor-
 tioned to the  resistance of the calculus, without however being ever
 increased to such degree as to break the forceps.   Under this point
 of view the dynamometric apparatus contrived by M. Benique, as well
 as all the other means hitherto proposed, in order to proportion the de- 
670
NEW ELEMENTS OF OPERATIVE SURGERY.
gree of percussion to the force of the instrument, appear  in my judg-
ment to be still less convenient and  less secure than the hand ham-
mer
  c.  If pressure with the hand should appear to be sufficient,the sur-
geon, who is always to be placed on the right, and with his back turned
towards the head of the patient, or to the outside, holding  the  litho-
labe  in the same way as in the  preceding case, glides his right hand
under the instrument, in order to embrace its root from below upwards
and from behind forwards between the middle and ring finger, while
the palm of this hand makes full pressure upon its button or plate, by
the action of the wrist.
  d.  On the supposition that the instrument was provided with han-
dles or traverses, as in that of  M. Bancal, for example, it would be
necessary that an assistant should fix its root firmly in  the direction
towards "the urethra; the operator being situated in front or upon the
side, then embraces the double traverses of the fixed branch, and of
the movable branch on each side, in order to press upon them with
all the force of his  two hands, and to make them glide on each other
while crushing the  calculus.
  e.  To effect ecrasement  by means of the screw,  the right  hand
causes the nut or the head-volant, or the virole-volant to turn, by a
mechanism which  is  too simple to make it necessary to describe it.
The  instrument, moreover, is fixed and  secured as in  the preceding
case.
  /.  The employment of the pignon is attended with no less facility.
The  stone being grasped, the surgeon holding the  litholabe with his
left hand in front of the urethra, adjusts and makes its key, which  is
applied on the left  side if he  is on the right, and on the  right side if
he is in front, act in the pignon of the instrument until its two branch-
es are approximated and closed.
  g. As  the  same instrument, among those which  are constructed
by M. Charriere, enables us at  pleasure to make use of the percus-
sion  hammer, the  dynamomelric lever, pressure with the hand, and
the nut  or volant,  or pignon, the surgeon may substitute one of these
manipulations for the other, and employ them in succession or alter-
natively, without changing anything in the rest of the operation, and
without being obliged to let  go  his grasp upon the stone, or to with-
draw the forceps.
  h. Should the calculus have once become broken, or escaped from
the forceps, its fragments are to be taken up  and crushed in the same
manner ;  we may  in this manner crush up 4, 6, 10 and 12, or even 15
fragments at  a single sitting, if everything goes on well, and the pa-
tient suffers but little, and should the whole sitting not extend beyond
ten to fifteen  minutes.  Should the calculus appear to  be very hard,
or make  resistance, it would be  imprudent to persist in crushing it.
We  let go our hold upon it in order  to grasp it in a different manner;
we strike upon it again with direct and sudden strokes.  It is in these
cases that percussion possesses a positive  advantage over pressure.
In cases however,  where the hardness of the calculus would seem to
make too great a  degree  of resistance, as I saw it do in the case
of M.  Desaugiers, and on  which  occasion  nearly  two thousand
strokes with  the hammer did not enable M. Leroy to  make any ap- 
LITHOTRITY
671
 preciable  impression,  lithotomy could still  be substituted  for litho-
 trity.
   i. Before withdrawing the instrument, we shut  it up completely,
 while cautiously avoiding to pinch up the bladder or inner extremity of
 the urethra between its branches.  Should portions of gravel, or frag-
 ments continue to remain attached between the branches of the litho-
 labe, they are to be separated from it. not by means of M. Leroy's
 rake,  (rateau,)  nor the  blade grater (lame-rape)  of M. Charriere,
 which can scarcely be combined with any other instrument than the
 stone-breaker of M. Jacobson, but by repeated drawer-like move-
 ments, and slight movements of percussion, or  by friction with the
 movable extremity, which is to be pushed one or more times through
 the aperture of the fixed branch, in such manner as to pass a line or
 two beyond its posterior plane.  It is so much the more  important
 not to omit these precautions, inasmuch as the forceps, when angular
 bodies have become entangled in it, may, as it comes  out, irritate or
 lacerate the urethra; and because  when   the instrument is thus
 rendered  too  large,  it  may moreover  become  wholly  arrested,
 either at the membranous portion,  or in the fossa navicularis of the
 passage.
   _;'. All the other attentions moreover, required by the operation, are
 in these processes, both in respect to their  manual and subsequent
 treatment, the same as in the processes with straight instruments.

                  § II.—Difficulties of Lithotrity.

   Notwithstanding the leather boxes, and the accuracy with which
 the three principal pieces of the apparatus set into each other, it some-
 times happens that the injection  escapes, between  them, or between
 the external  canula and the walls  of the urethra.   A small gutter
 which is made upon the dorsum of the sheath, and which communicates
 with the bladder by means of a groove which runs along  the outer
 surface of the litholabe, is added to some of the new apparatus, with
 the view of remedying this inconvenience.   We might in fact apply
 to this the syphon of  the  syringe,  and make use of it as a catheter
 to renew the injection ; but the irritability of the bladder soon places
 things  in the same  condition; fortunately the organ  rarely empties
 itself completely.
   A. Before puberty lithotrity is  attended with  less facility than in
 the adult, because of the  slight degree of development of the sexual
 organs, the small calibre of the urethra, the i-ndocility of such patients
 and the exquisite sensibility of the  parts.   The instruments cannot
have more than two to  two lines  and a half  in  diameter, which
sensibly diminishes  their  power, while at a more advanced age we
may give them  as much as four lines, although those of three to three
and a half lines generally suffice.   It is still  less adapted to the first
years of infancy, for the  reasons just given, and moreover because
the bladder, which is raised up too  much in  the pelvis, increases to
the same extent the curvature of the posterior third of the urethra,
and also because at this  period of life lithotomy presents  numerous
chances of success.  It does not however follow from this that  the
broiement of the stone is an impossible operation in infants.  MM. 
672
NEW ELEMENTS OF OPERATIVE  SURGERY
Lerov, Segalas and others have demonstrated  the advantages that
may be obtained from it at that period of life.  I have said only, and
I still maintain,  after  having frequently  verified the fact,  that  in
general it then involves more inconveniences than lithotomy.
  B.  The prostate, in  certain patients, renders the application of
lithotrity a  matter of considerable difficulty, in consequence of the
urethra  being pushed back behind the symphysis.  It is under such
circumstances that curved  instruments would, to some extent, become
a matter of necessity.   M. Leroy, struck with this circumstance and
with the view of lessening its gravity, and from having frequently
witnessed the danger or  the impossibility of using  straight instru-
ments, proposes a means which is very simple in appearance, which
he calls the adjuster (redresseur) of the urethra, and which  consists
of a  gurn-elastic  catheter  which is   introduced  curved, and  is
afterwards  to be  straightened when in  its  place  by means  of a
straight stilette, which  a  screw pushes gently into its  interior  from
before backwards.  This instrument, analogous to that proposed by
M. Rigal for the same purpose, and which, as has been remarked by
M.  Pravaz, the  lithotritor cylinder conducted  by means of  spiral
movements of the hand through a large flexible catheter opened at
its two extremities, might if necessary replace, exposes to the risk of
serious  inconveniences, and  to  the contusion of the verumontanum
and laceration of  the urethra, in  consequence of the screw or nut,
the force of which cannot  be calculated, and because the head of its
stilette cannot progress except by butting against each point of the
lower wall of the canal.  The instrument of M. Tanchou  being
formed  in its vesical third of a series  of small articulated  pieces,
which allow of its being introduced curved, and of its being straight-
ened when in its place witfiout making the slightest friction, would
be evidently  preferable if the straightening of the urethra  were a
precaution of actual importance in such cases.  An extreme degree
of development  in the prostate involves another inconvenience: it
sometimes, as I have said  farther back, transforms the  bas fond and
trigonus vesicalis  into  a  deep  cavity,  where  the stone cannot be
always  seized with facility,  unless after the  manner of M. Begin,
(Elem.  de  Chir.,  2e edit., Paris,  1838, p. 667,)  we should prefer
placing the patient on his knees  and elbows.  The  fingers of the
assistant or of the surgeon introduced  into the rectum, in order to
raise  it up and to present it to the  claws (serres) of  the litholabe
would answer full as well, I  conceive, as the little sac suggested by
M. Tanchou, or  the tampons, of whatever description they may be,
which might be introduced above  the anus.
  C.  In women, in whom M. Buret  (Bibl. Aled., 1828, t. II., p. 16)
has succeeded by means of a simple stone-breaker, lithotrity is  more
easy  than in man, and almost  unattended with danger.   As  their
urethra is large,  distensible, short, destitute of curvature, prostate, or
seminal orifices, it accommodates itself admirably  to the introduction
of the necessary instruments, and does not require as complete  a
pulverization of the calculus.  Only they have more trouble in sup-
porting and retaining the  injections, which however are  less neces-
sary in  a bladder which  is  naturally large, pliant, and, so to speak
exposed to view;  so  much so that M.  Segalas  succeeded in re- 
LITHOTRITY.
673
moving, in  a little girl  three years of  age, and after a very  few"
sittings, a calculus of large size, though no liquid could be kept up in
the bladder.  It must nevertheless be confessed, after what occurred in
the patients operated upon by MM. Bancal, Civiale, Leroy, Breschet*
&c, that as  lithotomy in women rarely  causes death in more than
one case out of twenty or twenty-five, it  would appear to be still less
dangerous in them up to  the present time  than broiement.
   D. The curved instrument, of M. Pravaz, (Bull, de Fer., t. XVII.,
p.  264; Gaz.  Med., 1833, p. 143,) M.  Pamard,  (Ibid., t. XIX.,
p. 71,) or of M. Leroy, being intended for the same system of broie-
ment as the apparatus whose  application I have just described, do
not require  any  other  details  for  the  operative  manual.  Their
principal advantage consists in occasioning less  annoyance  to  the
urethra, and causing consequently less pain, and of penetrating with
more facility into the bladder.   As on the other  hand they are  less
commodious than the others, for  exploring the organ and for find-
ing and  seizing the stone, it is unnecessary if we adopt the process
of perforations,  to employ them in women.  All other things being
equal, the straight instruments are to be preferred for lithotrity by
perforation, evidement or  concentric broiement; while  the  curved
instruments are better adapted to ecrasement.
   E. The instrument of M. Jacobson is one of the easiest to mani-
pulate ; there is not one which exposes less to the risk of wounding
the bladder.  As it consists of nothing more than a  single articula-
ted noose, and has neither  hooks nor free points, it would  be  almost
impossible for it to pinch up or  perforate the walls of the bladder;
so that we might if necessary use it without any  previous injection.
Its curvature renders its introduction as easy as that of an ordinary
sound.  The manner of  opening it is very simple. The  nut  having
been brought up to the end of the screw> the  palm of the right hand
is  made  to  rest  upon this exiremity.   We  push upon  it, and  the
jointed branch of the forceps immediately opens itself in the blad-
der, as if for the purpose of forming a racket circle,  which is some-
what irregular, in consequence of the dorsal concavity on the other
branch.  We proceed in search of the calculus after the rules  laid
down above.  When it has finally entered into the  metallic circle,
we act upon the screw first with the hand, in the same way as for
shutting up a litholabe, and then  upon the nut which is transformed
into a quick  screw, and which, by making the  two halves of the
stone-breaker act in the manner of two large files moving in  a con-
trary direction upon  the calculus, concentrates all its action on  this
last, and cannot fail of effecting the ecrasement.  The various frag-
ments which are thrown off, are subjected to the same researches  and
the same manoeuvres.  The surgeon has no  need of any assistant,
the patient experiences but little  fatigue, and nothing prevents  our
repeating the sittings  at  short intervals.  Finally, the position re-
quires no other  precautions than those  of catheterism  in general.
Only that it  is  unfortunate that  these advantages are counterbal-
anced by the greater difficulty of finding and seizing those stones that
are small, and of  satisfying ourselves whether they have oi have not
entered  into the noose of the forceps, also by  the impossibi ity of ex-
tracting any fragment of them, and by the pinching up of the pros-
   vol. in.                     85 
674
NEW ELEMENTS OF OPERATIVE SURGERY.
 tatic portion of  the urethra, which is sometimes caused by the slip-
 ping of the branches.
   F. Forceps with two branches.—The modern forceps, either those
 for percussion, those that have a volant or screw, or those that are
 intended only for simple  ecrasement,  may be employed with  still
 greater facility than the instrument of M. Jacobson.  As their ex-
 tremity may be turned to the right or left or backwards, they enable
 us to seize the  calculus  in  any of the  recesses of the  bladder.  As
 they admit of being opened  and shut without any effort, and with
 all the rapidity desirable, they do not require any support, and thus
 render the  operation evidently more prompt.   Their principal in-
 convenience is that of allowing the stone to escape from them with
 facility, and  that of reducing the calculus into angular fragments,
 which  disturb and irritate the bladder.
  G. M. Heurteloup, for the purpose of extracting these fragments,
 makes use  of a  large and  straight, or curved  catheter, the species
 of die  which forms the vesical extremity of which may be unscrew-
 ed at pleasure, and is designated by the name  of magasin.   Later
 ally, and at nearly an inch  from its inner extremity, it has two large
 apertures, which are placed in front of each other.  The  other  ex-
 tremity is provided with a stopper box, (boite a bouchon,) a fasset, to
 make injections, and a  ring, to  serve  as  a support to the fingers.
 The liquids, which by means of this instrument are thrown up into
 the bladder, bring with them as they return through the apertures,
 all such fragments whose  size will admit of their  passing through
 the instrument.  Those which are of larger dimensions are arrested
 in its apertures.   The author then makes  use  of a jointed  stilette,
 and  which is  flexible like  the lithotritor of M. Pravaz, in order to
 break or crush the projecting portion of the stone, and to crowd it
 to the bottom of the  magazine of the catheter,  while the other por-
 tion  of the calculus falls back again  into the bladder.  When after
 the repetition  of this manipulation a  greater  or less  number of
 times, the  magazine is found to be filled, the instrument is withdrawn,
 in order to unscrew and to empty  and reintroduce it, in order to
 repeat  the manipulation if it is deemed advisable.  M. Leroy alleges
 that  this object can be still  better accomplished by means of an in-
 strument of the same kind,  but in which the central stem  can act at
the same time both by pressure  and rotation.   Without rejecting in
an absolute manner the aid  of such instruments, we nevertheless feel
 compelled to avow that their probable advantages are not so evident
 as to induce practitioners to be anxious to adopt  them, or to sub-
stitute  them  for, or  even to associate them with, the  other instru-
 ments already known.

   § III.—Comparative examination of lithotomy and  lithotrity.

  The  broiement of the stone was scarcely invented, when its parti-
sans gave  it out as an operation altogether  innocent and devoid of
danger.  Some, moreover,  have considered that it was of such a
 nature, that it would  one day enable us  to dispense with lithotomy in
surgical practice.  The public has been deceived in  both these re-
spects.   Lithotrity, such as it is  now practised, is in the aggregate 
LITHOTRITY.
675
 Btill tu operation in many instances more painful  and more tedious
 than cystotomy; I have seen patients, and  among others one who
 was operated upon by M. Souberbielle, after having been treated by
 M. Civiale, affirm that one single essay at broiement gave them more
 Buffering than all the manipulations  of lithotomy.   A fourth, if not a
 third even, of the individuals upon whom lithotrity is performed, ex-
 perience accidents, and it is not true that it  never results in death.
 Out of 82 calculous patients mentioned by M. Civiale, 31 succumbed
 at the expiration of a year, and 19 others were not restored until after
 having experienced a certain number of accidents.  Out of forty M.
 Leroy was not enabled to effect the radical cure  of more than 25.
 Out of 10 M. Bancal accomplished it in only 2 instances, &c.; so
 that among a selected number of patients,  there dies at  least one
 out of every 10 or 12, and if we take an aggregate of calculous pa-
 tients, some of whom are subjected to lithotrity, others to lithotomy,
 or  left to  the resources of the system, there will perish at least, a
 sixth or eighth part of them.   Lithotomy, if examined in this point of
 view  alone,  will,  nevertheless, always  be still  the most  alarming,
 and the enthusiasts of broiement have no need of blackening the ca-
 talogue which relates to this operation, to disgust  the public with it,
 and deter patients from submitting to it.   Although authentic  details
 show, that out of 812 persons operated upon at  the Hotel Dieu and
 La Charite, in Paris, 255 perished, between  the 31st  of December,
 1719,  and the 1st of January, 1728, other facts demonstrate, that out
 of 213 Cheselden lost but 24.  Though M. Sanson says that  he has
 seen 6 perish out  of 20, Dupuytren, nearly  at  the same epoch, had
 operated upon 26 patients before he lost  a single one, and M. Dudley
 of the Transylvania University, met with the same success out of 72
 patients.   Without admitting the astonishing  cures imputed by some
 persons to Raw, and without conceding that this surgeon was enabled
 to succeed in 1500 operations in succession, instead of affirming only,
 that out of the totality of patients operated upon by him, he  had ef-
 fected 1500 cures,  it appears certain at least,  that Martineau lost but
 2 out of 84 ;  M. Pansa, of  Naples, 5 out of 66, Pouteau 2 out of 80,
 Lecat 3 out of 63, M. Pajola, of  Venice, about the same proportion,
 M. Viricel, of Lyons, 3 out of 83, M. Ouvrard, of Dijon, 3 out of 60,
 Saucerotte 1 out  of 60, and  that  Deschamps,  at one period, suc-
 ceeded in effecting 19 cures in succession. It is true that these facts
 are but imperfect.   The same practitioners have not always been so
 fortunate ;  but why should it not be the same  with lithotrity ?   Senac
 had  reason for saying that the greater portion of patients operated
 upon for lithotomy in the hospitals of Paris perished, since out of 29 in
 1725, at La Charite, 16 succumbed.   Another person, however, would
not have been wrong in  asserting  that there died but one only out
of 8 or 9 cases, for in the same establishment 22 were cured out of
25, in 1727, and 23 out of 26, in 1720; which, however, did not pre-
vent Morand from ascertaining that in this hospital 71  perished out
of 208 operated upon during the space of 8 years, while at the Hotel
Dieu, in the  same space of time  18  only succumbed out of 594.
Though M. Souberbielle lost  18 out  of 52, in  1824  and 1825, his
average proportion was not less than one out of every 6 or 8  opera-
tions.  Though M. Richerand has considered that the failures and cures 
676          NEW ELEMENTS OF OPERATIVE  SURGERY.
balance each other  equally at  the  beginning of this century, MM.
Roux and Dupuytren have set  them down in the proportion of 1 out
of 5 to 6.
  The following is what is exhibited  by the best accredited statisti-
cal tables  which have been published since the year 1810 :  At Nor-
wich, out of 506 there were 70 deaths ; at Leeds, 28 deaths out of
137  persons operated upon; at Bristol, 1  out of 4 and a quarter;
at Luneville, 1 out of 14 ; and in the table of Dupuytren, which com-
prises Paris  and its environs, there were since the year 1820, 61 deaths
Qut of 356 operated upon, that is, one out of every six.  Thus lithot-
omy causes  death in one case out of every 6 or 7 operations and no
more.   Lithotrity I  am convinced is less fatal; it would be necessary
however, to  know to what extent, but experience has not yet enabled
us to decide on  this matter.   In order  to determine  this  question
there is one  condition which conscientious persons should  not lose
sight of, which is this, that individuals who can be operated upon  by
lithotrity are precisely those in whom lithotomy would succeed the
best; while  almost  all those patients in whom  broiement would  be
inapplicable, have also fewer chances of being  cured  by lithotomy.
The solution of the  problem  therefore would  not be final, unless we
should select several hundreds of calculous patients for lithotrity, with
the view of afterwards dividing them into two equal parts, one of
which should be submitted to lithotomy and the other to lithotrity.
  Even though lithotrity  should be attended with still less danger, it
could not be applied to all cases. Those calculi  which have for their
centre a metallic body, pin,  needle, ball, &c., or for their nucleus a
fragment of  wood, horn or ivory, would  in general  be unsuitable for
lithotrity.  An Italian surgeon  completely failed in endeavoring to
break up a calculus  the nucleus of which was formed by a fragment
of the pith of wood, (Petrequin, Gaz. Med.,  1837, No.  42,) and M.
Leroy,  (Rev. Med.,  1836,1.1., p. 50,)  in a case where the stone had
formed upon a stem of wood, did  not succeed until after a num-
ber of trials. I  should however add, that  M. Cazenave found five
sittings sufficient (Gaz. Aled., 1838, p. 186) to break up and extract
a calculus  which had become encrusted upon an ear of wheat.  The
same difficulty occurs with encysted or adherent calculi, or those which
have become in  any manner whatever  immovable, those which  are
exceedingly  hard and which exceed the dimensions  of a pullet's egg,
and upon which  the bladder is  constantly applied, also in individuals
who have the urethra deformed, either from birth,  (as in epispadias
and  hypospadias,) or in consequence of disease, and to such extent
as to render the  employment of suitable instruments a mattei of too
great difficulty.  M. Franc, (Ext. des Calcules, p. 6,) who proposes
when the  urethra is diseased or contracted, that we should have re-
course to  lithotrity at  the hypogastrium, and who, like M. Dudon,
advises that  we should for this  purpose make use of a trochar armed
with a large canula, in order to  be enabled to introduce by that means
the suitable  instruments required of as large size as possible, calls to
his aid in this manner an operation  which is more dangerous than
lithotomy.  A great number of calculi, a considerable degree of conges-
tion in the prostate, or an ancient diseased condition and racornissement
of the bladder, would in the majority of cases make the operation of 
LITHOTRITY.
677
lithotrity  at  least as dangerous  as lithotomy.   Its  advantages  in
the other cases appear to me to be indisputable, except in infants, and
especially useful in those cases in which the patient is possessed of a
certain degree of fortitude and docility, and an irritability sufficiently
obtuse to  support the various manipulations without fear, and also in
those cases where the patient  has  a sufficient repugnance to  cut-
ting instruments to induce him to resign himself without difficulty to
the prospect of being relieved at the expiration of a greater or less
length of time, and where he can endure the introduction of the lithotri-
tic apparatus as  often as it shall become necessary for the purpose
of destroying the stone.   Though  the return of the disease is much
more  probable than after cystotomy, because of the fragments of
calculus which must frequently escape the most  minute researches,
we should not however hesitate in  having recourse to it, when there
is reason to believe that two, three,  four, five or six sittings will prove
sufficient.  Lithotomy therefore is incomparably the most alarming of
the two.   By it, it is true, the stone is more rapidly and more per-
fectly removed, and the sufferings,  so to speak, are momentary  ; but
the patient nevertheless is obliged to keep his bed or chamber during
the space of twenty or thirty days, while lithotrity, with the excep-
tion of the sittings, scarcely interferes with  his  customary occupa-
tions.
   A. Statistics of Lithotomy and Lithotrity.—I. Lithotrity.—At the
present day, which is eight years  since  the publication of the pre-
ceding remarks, it is still  almost impossible to  come  to any  other
judgment  on the  appreciation of lithotrity.   Its results have  been
given with so much  partiality that  science, in this matter, will have
to be almost  completely reconstructed.
   a. When, for example, we analyze carefully the facts taken from
the practice  of M. Civiale, who  considers that  he  has lost but six
patients out of more than two hundred, we find the following result:

   1st. For a first series of  83 calculous patients, we have 41 cured
     and 39 dead in  the course of  a year, and 3  who retained  their
     stone.
   2nd series,  24 patients,   13 cures,  11 deaths.
   3d   "      53     "     30   "     15   "      8 retained  their
   4th   "      30     "     18   "      8   "      4        [stone.
   5th   "      16     "      6   "      7   "      3      "
or out of an aggregate of:
   6th        429 patients, 268 cures,  161 not cured.

   As M. Civiale has complained of this calculation, I have re-exam-
ined his observations separately, one by one, and obtained the foliow-
.ng result  from his first table:

   1st observation.   The size of the stone not mentioned ; cured.
   2nd     "         Stone friable and small;  cured.
   3d      "         Size of a nut;  cured.
   4th      "         Size of a  nut  and friable;  operation difficult;
                     cured.
   5th      "         Size of an almond; operation difficult; orchitis;
                     cured. 
678
NEW ELEMENTS  OF OPERATIVE SURGERY.
6th observation.		Size of a small egg ; dead.
7th	«	Size of a nut; fever and accidents ; cured.
8th	H	Stone friable; difficult; disease returned.
9th	ii	Size of an almond ; dead.
10th	((	Two calculi; cured.
11th	a	Size of a small nut; cured.
12th	<■	Small and friable; woman ; cured.
13th	a	16 calculi; three months of treatment; cured,
14th	u	Size of small egg; cured.
15th	u	Size of nut; returned, and died one year after.
16th	it	Stone flattened; cured.
17th	(i	Several stones; cured; difficult
18th	t(	Size of almond ; cured.
19th	M	Friable ; returned ; died one year after.
20th	M	Size of an egg ; cured.
21st	it	Several stones; cured.
22nd	it	Large, friable ; died in a month.
23d	a	Several small calculi; cured.
24th	a	Several stones ; died two months after; re-tention of urine.
25th	a	Nut; friable ; cured.
26th	«	Large stone; operation difficult; cured.
27th	M	Large and friable; cured.
28th	«	Nut; cured.
29th	M	Many ; treatment of several months ; cured.
30th	(«	Small, friable; cured.
31st	K	Small; cured.
32nd	it	Nut; difficult; cured.
33d	It	Small, friable ; died three months after.
34th	it	Small.
35th	ti	Nut; two months of treatment; cured.
36th	it	Many; size of a nut; 2 mos. treatment; cured.
37th	it	Medium size ; treatment tedious; cured
38th	ti	12 lines; cured.
39th	it	Friable; cured.
40th	tt	Medium size; returned.
41st	it	Voluminous; cured.
42nd	tt	Small; cured.
43d	it	.. tt
  Other facts which M. Civiale does not take into consideration, have
nevertheless a certain  degree of value ; I extract them  from his
book:

             Gervais. Essays ?  Lithotomy performed.       Dead.
             ----------------  Stone 5 ounces.
             Baticle; preparatives and lithotomy performed.    "
             Count de  Bournon ;  stone  broken up ;  lithoto-
               my performed.                                «
             Admiral Leroy ; lithotomy performed.            «
             Bonleu; explored;   "         «                 „
             Demausse;          "         «                 u
             Bellefond;  "       "         «                 „
Page xxxiv.
  "   xxxv.
 xli,
 xlii.
xliii.
xliv. 
LITHOTRITY.
679
Page
 XII.
 xiii.
  «
 xiv.
 xvi.
xvii.
xviii.
 xix.
 XX.
 xxi.
xxii.
      lviii.
"      Ixv.
" •  cxlviii.
"     clvii.
      clix.
"   clxxiii.
"   clxxix.
"   clxxxi.
"  clxxxiii.
" clxxxviii.
"    xxviii.
"       XX.
"     xxxi.
"    ccxv.
"     cciv.
Pallu.
De Tascher ; broken up.
Diernot;
Montessu;  explored.
Combes,
Dead.
oomoes.
Desrenaudes.                                 "
Vincent; broken up.                          "
Chevals ; died during the preparatory treatment.
Fayau; broken up.                            "
Regnauld.
Faure;  broken up.
N.; explored.
Labat;  attempt to break up.
Chetelal;  explored.
Chetelal
Farder.
Aumont;  broken up.
Quartara; essays.
Balet; broken up.
Viollance; "
Huet;     "
Lebaigue; "
Azille ;
Provosty, a physician; ~
Dallery.
Leblanc Lavalliere; essays.
Carpenter; broken up.
Jule Perin.
ex
:plored.
As for the rest I have made use of subsequent publications of M.
Civiale, M. Larey, M. Double and M. Ledain, and valuable informa-
tion which has been furnished  me  by ocular witnesses, or which I
have myself taken on the spot.
  b.  Without  measuring  by the same rule the successes announced
by M. Heurteloup, who states that he has succeeded 37 times in 38
patients; by M. Leroy who lost only 11  out of 116 operations ; and
by M. Bancal  who, in 1838, lost but one out of 23, it is nevertheless
allowable not  to take literally  the  statements of those gentlemen.
The English journals of medicine, in fact, together with the letters
of M. Key and of M. B.  Cooper and M. Tarral, as also the lectures
of MM. Brodie,  Liston and Chas.  Bell, show that several  of the
patients of M. Heurteloup had deceived the operator, and that  they
were not cured when their cases were published.  In the twelve cases
of lithotrity taken by M. Doubowitzki, (Reprod.  Fid. des Discuss.,
fyc, 1835.) from the  practice of M. Amussat, we find five positive
cases of cure,  four of doubtful success, and three instances of death.
Though  M. Amussat has formally denied  this,  it  is certain  that
the Count D'Auxi, among others, died  after the  expiration of a few
months without ever having ceased to suffer, and that there were
still remaining three or four small calculi with facettes in his bladder.
The patient operated upon by M. Civiale at Florence in 1835, was not
cured.  At the Neckar Hospital, at the  same period, there  died at
'east two out of six or eight.  A merchant of Lyon, a patient from 
680
NEW ELEMENTS OF OPERATIVE SURGERY.
Anjou, another from the country, two from the department of Seine and
Oise, the husband of a midwife at Paris, a printer, a patient of M.
Roux, two of mine, one of M. Lenoir, the English Colonel Rankin,
another personage of the same country, a case operated upon by M.
Attenbury, a patient of M. Olknow, one  of M. Colliex, and  one of
M. Norris, and others also have alike succumbed under the operation
of lithotrity.  It would be therefore, I  repeat,  to abuse the public, to
give out this operation  as destitute of every kind of  danger.   M.
Bancal  having 53 calculous patients to  treat, (Clin. Civil.,  fyc,
Bordeaux, 1839, in 8vo.,) attempted broiement in 30 ; 22 were cured,
7 gave  it up,  and 1 died.  Thev were  of the following ages:  72,'
60, 78, 74, 45,  66, 59, 40, 70, 35, 68, 34, 70, 72, 70, 37, 52, 64, 77, 74,
63, 52, 76, 75,55,52, 32,60,56, and 78.   Twenty-three patients were
subjected by this practitioner to lithotomy:  6 died and 17 were cured.
Those who survived were of the following ages: 77 (with 55 calculi),
70 (3  calculi),  50 (1 calculus), 69 (1 calc), 70 (3 calc), 68 (8 calc),
50 (1 calc), 72 (1 calc), 66 (1 calc), 60 (1 calc), 70 (25 fragments
by the lithotritor), 32 (1  calc), 70 (7 calc), 60 (7 calc), 6 (1 calc),
10 (1 calc), and 68 (15 calc).  The ages of those who died were:
80 (3 large calculi), 22 (1 large calc),  56 (2 large calc. and the blad-
der bilobate), 84 (10 calc), 66 (1  large calc),  and 58 (1 large calc);
from whence it appears that  in 22 it was practicable to perform
lithotrity to the end of the treatment, while 31 had to be subjected to
another course of  remedies.   But this table  scarcely accords with
the first publication of M. Bancal, since, out of 13  patients whom he
then mentioned, 4 of them died, one or two were cured, and 7 gave
up the process.  M. Randolph, (American Journ.  of Med. Sciences,
Nov.  1834, '36,) who asserts  that he has performed  lithotrity 13
times successfully, does not declare that he has  never failed in it.  In a
patient  in whom lithotrity was attempted with a percussor, which
made a false track, it resulted  in death and became in  this way the
subject of an inquest in England, on the part  of the College  of Sur-
geons, (Gaz. Med., 1837, p. 676.)  With M. Tonelle however,  (Precis
Mid. d'lndre et Loire, 1838, p. 83,) who has  already performed this
operation a great  number of times with success, three  sittings were
found sufficient to relieve a patient of a stone as large as an egg.
M.  Breschet also (Gaz. Med., 1838, p. 184)  made use of lithotrity
successfully in a woman who had suffered for the space of ei^ht
months.  It has also  been performed with success by M.  Bonfils,
(Trans. Aled., t. XL, p. 264,) M. Liston, (Bull, de Fer., t. XVII.J
   &400,)  M. Wattemann, (Ibid., t. XVI., p. 440;  t. XVIII., p. 73,)'
  . Randolph, (Account of six cases, fyc, 1834 ;  American Journ. of
Med.  Sc.,) M. Depeyre, (New York Med. Journ., February, 1831.)
M. Cazenave, (Oper. de Lithotrit., fyc, 1837,) and  MM. P. Guersant,
Blandin, Sanson and Payan;  but a patient, who was operated upon
by M. Castara, (Journ. des Conn. Med.-Chir., t.  III.,  p. 368,)  died
from cystitis, and that of M. Lallemand (Lafosse, Clin, de Alontpelier
fyc., p. 19) from purulent infection.
  c. In what relates to myself, I count up to  the present time (May
1839) but twelve cases in lithotrity:                         v   Jt
  1, Man; 55 years; calculus  size of a large nut;   two sittings; 
LITHOTRITY.
681
calculus badly seized;  pains quite acute, which vexed the patient,
and he went to a specialty practitioner; straight instruments;  1827.
   2.  Man; 32 years; calculus like a small nut; seized and broken
up in one sitting; litholabe with three branches; 1829.
   3.  Man; 61 years; calculus size of a large nut;  perineum pain-
ful ; cystitis distinctly pronounced ; an essay with M. Sirhenry's for-
ceps ; urinous collections ;  nephritis; death; ulcerated urethra; kid-
neys in state of suppuration ; 1831.
   4.  Man ; 58 years; calculus flat; fruitless attempt with  M. Tan-
chou's instrument; patient cut and cured ;  two inches and a half in
the great diameter of the calculus ; 1831.
   5.  Man ; same age ;  ineffectual attempt with the apparatus of M
Pravaz ; no accident; cut; cured ; 1832.
   6.  Man ; 57  years of age;  calculus like a  small  egg; thirteen
sittings; success; instrument of Jacobson;  1834.
   7.  Man ; 65 years ; calculus of moderate size ; six sittings ; suc-
cess ;  instrument of Jacobson ; 1834.
   8.  Man; 68 years ; size of large nut;  three easy sittings; cys-
titis ; acute nephritis ; death ; 13 fragments  in  the bladder ; instru-
ment of Jacobson ;  1834.
   9.  Man;  58 years; size of pullet's egg; seventeen sittings; suc-
cess ;  Heurteloup's pressure  forceps, with screw and volant; 1835.
   10.  Man; 54 years ;  numerous stones ;  prostate diseased ; will
undergo lithotrity at  any hazard ; four  easy sittings ; 60 fragments
expelled ;  cystitis;  nephritis;  death;  73  calculi intact; 95  frag-
ments ; fungus of the prostate, and kidney in suppuration; Heurte-
loup's instrument as modified, tried  once;  Jacobson's brise-pierre
three times : 1836.
   11.  Man; 69  years;  calculus like  a small  nut; three  sittings
rapid success;  pignon forceps;  1837.
   12. Young man ;  20 years ; calculus size of an egg; does not wish
to be cut on any account;  first attempt  easy; stone broke twice
with the pignon  litholabe.   Second attempt—patient extremely in-
tractable ; violent and incessant contractions of the  bladder; sud-
den erections of the penis on the slightest movements of the forceps.
Third and fourth attempt fully as  ineffectual; lithotomy performed ,
success prompt;  1837.
   In  examining the results furnished by lithotomy in different coun-
tries, M. Civiale, it is seen, has  singularly imbrunated the  table, so
that on this  point, as well as  in  what  relates to  broiement, the
works of this practitioner, from the first  to the last, are only calcu-
lated to mislead the reader into the strangest delusions.
   II.  Lithotomy.—The following now is what the  tables furnish  in
respect to lithotomy.
   M. Dudley,  (The  Lancet, 1838, vol. II., p.  307—London Med.
Gaz., June,  1837, p. 448—Transylvania Journal, &c, vol. X., p. 91.)
Out of 148  patients, 10  refused  to be  operated upon.   Out of 138
operated upon, 131 were cured ; 4 died, 1 of pleurisy, 2 of nephritis,
1 of disease of the liver, though  the wound had cicatrized; and 3
had a fistula succeed to the operation.
   Brett, (Kleiner?s  Repertoire, March, 1835, p. 163.)  In India out
of 22 cases of operation, 4 patients died from exhaustion.
   vol. in.                      86 
682          NEW ELEMENTS OF OPERATIVE SURGERY.
  Clot, (Compte Rendu d'Abouzabel, 1832, p. 49.)   Out of an ag-
gregate of 58 patients, 6 died.
  Pansa, (Naples, 1827, Bull, de Fir., t. XV., p. 66.)  32  cases, 5
deaths.
  Kern, (Bull, de Fer., t. XV., p. 64.)  Lateral method ; 334 cases
and 31 deaths.
  Burnard,  (Arch.  Gen.  de Med.,  2e ser., t. I., p. 427.)   At the
Hospital of Benares at Bengal; out of 22 operated  upon, 5 deaths.
Cheselden,	213	operated upon,	24 deaths.	
PoUTEAU,	80	«(	2	it
Martineau,	84	«	2	ti
Saucerotte,	60	a	1	it
Deschamps,	20	tt	1	it
Viricel,	83	it	3	a
OuVRARD,	60	it	3	a
Pajola,	50	tt	5	a
Dupuytren,	27	a	1	tt
a	70	it	6	a
Mejean,	105	it	1	a
Delmas,	11	tt	1	a
  Hotel Dieu, and Chariti, from 1719 to 1728, 812 operated upon,
251 dead.
  At Luneville, for the same period, 1629 operated on, 147 dead.
  Cross, at Norfolk and Norwich, mentions 704 calculous patients, of
whom there were:
    Men,
    Women,
At Leeds,
669 cases,
 35  "
197  "
478 cures,
 33  "
 33  "
91 deaths.
 2   "
28   "
At Naples, (De Renzi, Gaz. Med., 1835, p. 217,) in fourteen years:
Petrunti,
Santoro,
Smith,
Souberbielle,
F. Jacuues,
F. Come,
Ciielius,
Mott,
440 cases,
 25
 56
 17
133
 60
 38
 50
 23
100
 22
 50
375 cures,
 24   "
65
 1
 1
deaths.
at Brussels,
" Versailles,      "
" Angers,         2
" Hotel de Lorges, 1
     81 cures,     19
                  1
                  1
17   "
no deaths
  b
Ste
     Out of 1411 calculous patients, received into the Hospital of
    Marie at Moscow, from the year 1808 to 1836, there were  411
operated upon fro/n 1829  to 1837.  Out of these  last 369 were
cured; 41 were not cured at the time of their leaving ;  42 suc-
cumbed ; 17 died without being operated upon ;  46 were from 15 to
62 years of age, and 323 between 1 and 16 years;  11 of  the first
succumbed, and 31 of the  second.  M. Roos, (Gaz. Mid.,  1838, p
810,) says nothing of those that  were operated upon before  the 
LITHOTRITY.
683
year 1830.  According to M. Franc, on the contrary, (Extrait des
Calculs, &c, p. 10,) who has frequented the hospitals of Montpe-
lier, out of those operated on by lithotomy, as many die as are cured.
It must be admitted, however,  that the accuracy of these propor-
tions is not placed beyond all dispute, and that the facts which serve
as their basis, are not accompanied with all  the  details that are de-
sirable.  The series given by M. Cross is one of the best which wa
possess.   Out of 704 patients mentioned by him there were :
  Children from 1 to 10 years,  281 cases,  262  cures,  19 deaths.
      "     "11 " 20  "     106   "     97   "    9    "
  Adults    "  21 " 50  "     143   "    125   "   18    "
      "     "  50 " 80  "     174   "    127   "   47    "
  c. The  weight of calculi.—Out of 271 patients in whom the calcu-
lus  weighed more  than  5 gros, 215 were  cured and 56  perished.
Out of 529 in  whom the calculus weighed less than  an ounce, 47
succumbed and 482 were cured.  Being desirous of ascertaining if it
was possible to estimate the  dimensions of a calculus by means of its
weight, I  took several of those that are in the museum of the Facul-
ty of Medicine, and after having requested M. A. Thillaye to examine
them, I obtained the following facts:

  1st.  The calculus of a flattened  ovoid shape,  was formed  of uric
acid.
     The great  axis was 42 millemetres, or  19 lines.
         small  axis  "  33        "       1 inch and 3 lines.
         thickness   "21        "       9 lines and half.
         weight of this calculus 21 grammes, or  5 gros and 36 grains.

  2d. Calculus of a flattened ovoid form, (uric acid ?)
           37 millemetres in one diameter, or 19^ lines.
           31       "        another    "    13f   "
           Thickness 25 millemetres,       or 11^   "
           Weight of this calculus 19 grammes, 6., or 5 gros, 8 grs.

  3d. The calculus mural of spherical  form and covered with as-
perities, (composed of oxalate of lime.)
    Diameter 39 millemetres, or 20^ lines.
    Weight  46 grammes, 6., or 1 ounce, 4 gros and 13 grs.

  From whence it  follows that every calculus  of half an ounce in
weight ought to have nearly an inch in diameter.
  d. I owe to  the politeness of M. Castara, an unpublished table,
which is still more valuable than that of M. Cross, and which I pre-
sent on the following pages.   It relates to the patients operated upon
at Luneville, from the year 1738 to  1828, and must be received as a
guide or supplement to that of Saucerotte. 
684          new  elements of operative surgery.
Hospital of Luneville.
	Number	Sex.		Deaths.			Mor-		
	of calcu-					Mortality among	tality	Mortality	
Age.	lous		«		|		among	in the	Operated on a second time.
	patients	»	—	«	■j	Males.	Fe-	two sexes.	
	operated	75	2	"5	=		males.		
	upon.	S 17		3	^				
2 to 3	18					1 in 5 2-3		1 in 6	2 1 after 1 year 1 after 3 years.
3" 4	82	79	3	4		1 " 10 3-4		1 " 20 1-2	2 1" 6mos. 1 " 3 "
4" 5	135	131	4	8		1 " 7 5-8		1 " 7 1-2	2 1 " 6 mos. 1 " 4 "
5" 6	145	141	4	10	1	1 " 17 5-8	1 in 4	1 " 15 2 3	2 1 " 6 mos. 1 " 4 "
6" 7	144	13.)	5	16		1 " J3 9-10		1 " 14 2-3	
7" 8	119	113	6	5		1 " 18 5-6		1 " 19 5-6	
8" 9	119	116	3	0		1 " 23 2 5		1 " 23 4-5	1 after 2 years.
9 " 10	88	84	4	H		1 " 8 2-5		1 " 8 4-5	2 " 6 mos. 1 " 9 "
10 " 11	76	73	3	13		1 " 6 7-12		1 " 6 10-11	
11 »I2	52	49	3	6		1 " 16 1-3		1 " 17 4-3	1 " 2 years.
12 «• 13	72'	70	2	6		1 " 11 2-3		1 " 12	1 " 6 mos.
13	52	48	4			1 «• 8		1 *' 8 2-3	
14	28	27	1	2		1 " 27		" 27	
15	36	34	2	4		1 " 17		1 " 18	
16	36	35	1	5		1 " 8 3 4		I " 9	
17	30	30		9		1 " 6		1 " 6	
18	33	33		2		1 " 3 2-3		1 " 3 2-3	
19	90	20		4		1 " 10		1 " 10	
20	20	20				1 " 5		1 » 5	
21	14	14		3		1 '• 14		1 " 14	
22	15	15		2		1 " 5		1 " 8 1-2	
23 .	17	15	2	2		1 " 7 1-2		1 '< 8 1-2	
24	12	11	T			1 « 5 1-2		1 " 7	
25	7	5	2	1		1 " 5		1 " 7	
36	7	6	1	1		1 " 6		1 " 3 1-2	
27	7	7		2		1 " 3 1-2		1 " 6	Strictly speaking we ought not
28	6	6		1		1 " 6		1 " 6	here to include in the necrology of
29	6	6		1		1 " 6		1 " 2 1-2	cystotomy three patients operated
30	5	4	I	2		1 " 2		1 " 3	upon, who died, one on the 21st
31	3	2	1	1		1 '< 2		1 " 3	day after the operation, from a
32	3	3		1		1 " 3		1 " 3	confluent small-pox ; the second at
33	3	3		1		1 " 3		1 " 1 1-3	the end of a month, from an abscess
34	4	3	1	2	1	1 " 1 1-2	1 in 1	1 " 5	in the kidneys and colliquative di-
35	5	5				" 5		" 6	arrhea ; the last on the Ihird day,
36	6	5	1	1		1 " 5		1 " 2	but in a state of marasmus, with
38	4	4		2		1 " 2		1 « 3	the kidneys and lungs in a state of
39	3	3				" 3		1 " 5	suppuration.
40	5	4	1			" 4		" 2	On making the post-mortem ex-
41	2	2				" 2	~	« 2	amination of a child 8 years of age,
42	2	2				" 2		» 2	a calculus was found in the ura-
43	2	2				1 " 2		1 " 2	chus of a different nature from the
44	2	2				" 2		" 4	one extracted from the bladder.
45	4	3	1			" 3		« 2	
46	4	4		2		"		1 " 1	
47.	1	1				" 1		u 4	
50	4	4				" 4		• > 1	
51	1	1		1		1 " 1		1 « 1	
53	1	1				•' 1		>• 2	
5~	2	2				'• 2		.. 3	
54	3	2	1	I		1 ■' 2		1 » 4	
56	4	4		1		1 » 4		1 '• 2	
5P	2	2				" 2		1 " 1	
56	1	1				" 1		" 2	
60	2	2		1		1" 2		1 » 2	
61	2	2				" 2		.< 2	
62	1	1				" 2		« 3	
63	3	3		1		1 * 3		1 << 1	
64	1	1				" 1		« 1	
C5	1	1				" 1		« 2	
66	2	2				" 2		» 1	
68	1	1				" 1		u 2	
70	3	3		1		1 " 2		1 » 2	
73	2	2				" 2		« 1	
74	1	1				" 1		» 1	
76	»	1				" 1		" 1	
78	1 1492	1 1433	59	148		" 1		" 1	------------_J
Total,					21	1 in 9101-148	1.29 1-2	1 in 9 71-75	
 
LITHOTRITY.                               685
Table of Operations in Private Practice.
	Number ofcalcu-	Sex.		Deaths-		Mortality	Mor-tality	Mortality	
									
Age.	lous		2		»	among	among	in the	Operated on a second time.
	patient*	M	"3	u	d	Males.	Fe-	two sexes.	
	operated	"3	5	"3	E		males.		
	upon.	S	6-	S	£				
5 ton	1	1							,
5" 6	4	4	—	—	—	----	—		1 a year after.
									
6" 7	5	5							
7" 8 8 "10	6 4	4 3	2 1						1 a year after.
									
10	2	2							
11		1							
12		1							
13	2	1	1						
17			1						
19		1							
20	2	1	1						
22		1		1					
24		1							
25		1							
30			1		l*				
36 40		1 2		1					one year after.
									
45 50			1						8 months after.
		2							
51		1							
55		1							
60		1							
62 65		r		It					
68			1						
Total,	46	37	9	3	l				
  * We would remark that this woman died from phthisis pulmonalis, the 30th day after
the operation.
  t This old man, who had suffered for a long time, was exhausted by fever and diarrhoea;
his bladder was much affected.  He  sunk quietly a month after having been  operated on.
The operations on the males were performed with the improved gorget of Hawkins, save one,
who was operated on by the recto-vesical method.  Of the nine female patients, five were
operated on  by the bi-transverse incision of the urethra and  neck of the bladder, three by
the vertical incision, and one by the vagina.   An old man of 62 years of age, and a woman
of 68, remained with incontinence of urine. 
686          NEW ELEMENTS OP OPERATIVE SURGERY.

  e.  M, Castara adds, that out of 1133 patients of the male sex, 1103
were operated upon by the method of Marianus, or that of the great
operation;  of these 119  perished, which  makes the  mortality  1  m
every 9^\ parts, while 7 had fistulas follow.  There were  330 cut
with the improved gorget of Hawkins;  out of these  29 perished,  or
1 in e verv 11 T\\\, and 3 had fistulas.   Out of 59 of the female sex ope-
rated upon, it was effected by dilatation of the urethra m 50  cases;
there were 2 died, and 9 were.submitted to the bi-transverse incision
of the urethra and neck of the bladder.  The majority of these calculous
patients were furnished by the  towns and communes situated to the
south in the Department of La Meurthe.   Their frequency  appears
to have diminished in this department.  The town of Luneville fur-
nished  between the years 1738 and 1828,  90 cases, of whom  6  died
in consequence of the operation.
     1st.  In a period of 30 years, 56, or 1 and +£ per annum.
     2d.  In a second period,     30, or 1           "
     3d.  Finally, in a third period, 4, or      T2T     "

  From whence  it follows that there has taken place  a diminution  of
yj in every period of 30  years.  It will be remarked, says M.  Cas-
tara, that the table published by Saucerotte differs from mine in re-
spect to the number upon whom lithotomy was performed, and  in
what relates to the results of the operation.  The registers of lithot-
omy in our hospital do not go back beyond the year 1738.   I have
made  an  exact  transcript  of  them.   I have  myself  collated the
copy with the original, and with those  documents which came 'into
my possession from my ancestor, Sebastian Castara, who was sur-
geon of the Hospital of San Jacques  and lithotomist  of the founda-
tion  of King Stanislaus, at the same  time with  Saucerotte.   I have
carefully abstracted quite a considerable number of patients,  who
were  not  operated  upon,  or  who died before the operation,  or
who are found in this list only under the head  of fistulous cases.  It
results from this, that from  the year  1738 to  1828, there were but
1492 calculous patients operated upon,  of whom 59 were of the  fe-
male sex.   I do  not know where Saucerotte derived his information
of an anterior date, but I am induced to  believe that in his work  he
has fallen  into a  number of errors.  He states that up to the time at
which he wrote, there had been 1629 operated  upon, and 683  after
Ihe time he become attached to the hospital as lithotomist.  Now it
was in the month of August, 1765, that  he performed his first opera-
tion in lithotomy, and from that epoch to the date of his book in 1801,
even if we include  that year, there were but  653 operations;  of
which 624 were on the male sex and 29 on the  female.  In the first
there were 63 deaths, or  1 in 9|^ operated upon; in the other there
 were but two: the mortality in the two sexes united, is one out of
every  lO/j.  It  is in this catalogue that are found the 194 calculous
patients operated upon by Saucerotte  and his  colleagues by means
of the  modified gorget.   I consider however that we  may reckon  the
cases at 196, and 12 deaths instead of 10, which gives a mortality of
one  out of every 16^.  I do not desire  to depreciate the advantages
of the cutting gorget, for it is the instrument  to which I give  the
 preference; not Desault's modification, but the gorget which was 
LITHOTRITY.                        687
used  by my  -grandfather  and father, and which  is quite similar
to that of Scarpa.   My only desire is to  establish the fact6 and ap-
proach as near as  possible  to the truth.   A mortality of 1 out of
every 16, would still be a satisfactory result, in uniting  together the
persons operated upon at every age; but  the statistics in this respect
are based upon too small a number of observations to allow us always
to hope for so favorable an issue.   I  find in fact a succession of 20,
30, and even 50 operations by the great operation, without encoun-
tering a single death.  Could  we  conclude from  thence  that we
should not lose but 1 out of every 20, 30, or 50, by  the process of
Marianus ?  Certainly such a result could not be possible.   Failures
immediately afterwards make  their  appearance, and soon destroy
our hopes and dispel our illusions !  With the desire  of ascertaining
the difference in the chances of success  between the two operative
processes, (Marianus and Hawkins,) I have divided into three periods
of 30 years  each, the  space between the  years  1738 and 1828.  In
the first there was no other than the great operation; the second
embraces both methods; while  the third, in fine, includes only those
cases that were operated upon  by the modified  gorget, except two
cases by recto-vesical lithotomy.
   First period,   836 operated upon, 96 deaths, or 1 in every 8|f.
   Second period, 538      "        45    "     1     "   ll£f-
   Third period,  118      "         9    "     1     "   13|.

   C.  Like all those operations which some persons undertake to per-
form under the title of speciality, lithotrity soon became the object of
mercenary  speculations  much  more than  it did the subject of re-
searches purely scientific.  From that time it became quite natural
that they should make light of  its inconveniences, at the same time
that they exaggerated the dangers of lithotomy.   Having seen per-
formed, and having myself practised both the operations to a very
considerable extent, I am enabled to  compare their value in all their
relations.
   B.  Dangers of Lithotrity and Lithotomy.—I.  The danger of litho-
trity is ascribable, even in the modern processes to:
   a. The pain, which  is sometimes  very acute.  Some persons ex-
hibit more impatience under it than in lithotomy, and complain as much
at each sitting, as they would from this last operation. This pain appears
to be produced by the distension and  the straightening of the urethra
which the lithotritor, which necessarily occupies a straight position
under the pubes, causes the patient to experience in the membranous
and prostatic portions of this  passage.
  b. To the nervous symptoms.—Certain patients experience so much
distress during the broiement,  that  such severe nervous symptoms
are thereby  speedily produced as to result occasionally in death.  M.
Larrey and  M. Leroy have each given a  case of this kind.
  c. To the fever.—A  fever,'which shows itself under the form of an
intermittent, is  frequently the consequence of any  attempt at litho-
trity,  whatever may be the method we adopt.   It is frequently an-
nounced by' chills and a violent trembling ; the hot and afterwards
the sweating stage arrive, and  the accident may stop there, but it is
not unusual to find a febrile pulse continue for two or three days. 
688
NEW ELEMENTS OF OPERATIVE SURGERY.
  d. To the arthritis.—Pains in the joints similar  to rheumatism
and  which  sometimes become  the  source of dangerous  purulent
arthropathy, in some cases succeed to these exacerbations of fever.
  e. To the urethritis.—The irritation which lithotrity leaves in the
urethra frequently confines itself to the production of a slight blenor-
rhagic  exhalation, which  disappears  in the course  of two  or three
days.   In some cases also  the pain is so acute in  the perineum  as to
occasion suffering when the urine is emitted, and to oblige us to defer
the sitting to the expiration of a week or more.
  /. To abscesses of the prostate.—When  there has been very con-
siderable contusion and pressure upon the urethra, the prostate itself
may inflame and  terminate in abscess.  Instances of this result have
been related by several practitioners.
  g. To the tearing and laceration of the urethra.—The straighten-
ing which we  are obliged  to give to the curved  portion of the  ure-
thra, frequently causes this  passage to be excoriated, or  torn, or
lacerated, from whence is  produced a sensation of burning,  which is
very painful at the time the  urine and fragments of stone are pass-
ing through it.
  h. To the urinary infiltration, which is almost  a necessary conse-
quence  of the preceding accident.
  i.  To the collections of the  same nature, which  unavoidably follow
upon the urinary infiltration, and  the serious danger of which is well
understood.
  j.  To the orchitis,  which very frequently takes place, and which
succeeds, as in  blenorrhagic  orchitis,  to the irritation established in
the prostatic region of the urethra, but which is not  in general of
long duration and does not always prevent-our repeating the opera-
tion.
  k. To the phlebitis,  instances of which have been related by M.
Leroy  and some other practitioners, and which either as a  cause or
effect, is neither more nor less dangerous in this than it is in  all other
cases.
  1.  To the cystitis, which has been frequently observed and pointed
out, and which is explained  either by the repeated contact of the
instruments, or  by the angular condition  of the fragments deposited
in the bladder by the  breaking up of the  stone.
  m. To the perforations of the bladder, even  the possibility of
which has  been denied, but instances of which were noticed in the
patient Turgot, and in other cases mentioned by MM. Breschet, Tan-
chou, Bancal, &c.
  n. To wounds of the rectum, which can scarcely exist without the
preceding injury, and the  least dangerous  result  from  which would
be a recto-vesical fistula.
  o. To the pinching up or lacerations of the mucous membrane of.
the neck or body of the bladder.   From being obliged to pass through
a common sheath and to  make friction  against  each  other at their
root near the calculus, the branches whether of the forceps with two
branches, or the noose of  Jacobson, or the  straight litholabes and in
fact of all lithotritic instruments, expose to the risk of this inconveni-
ence, which, whatever may be said to the contrary, frequently occurs,
but fortunately is rarely attended  with serious consequences. 
                          LITHOTRITY.                       689

  p. To the hemorrhage, which apart from a slight exhalation from
the urethra, but rarely takes place, but  of  which MM. Tanchou and
Blandin alone, however, relate four instances in which it became of a
serious character.
  q. To the retention of urine, which is attributable to the irritation,
congestion and lesions of every kind, which take  place  at  the neck
of the bladder and  in the prostatic region of the urethra, or it may
be owing  to fragments of calculi which have become arrested under
the pubes.
  r. To the incontinence of urine, which  arises  from the contusion
and distension of the same parts.
  s. To the impotency, which is explained in  the same  manner from
injuries to the ejaculatory ducts and their relations with the  prostate.
  t. To the fragments arrested in the urethra, sometimes behind the
meatus, in the fossa navicularis, whiflh is not serious, sometimes in the
prostatic  region, Which is much more  grave, and  which frequently
occasion  excruciating pain, and the greatest degree of embarrass-
ment.
   u. To the fistulas of the rectum, perineum or urethra, which are
nothing more than the results of some  other lesion.
   v. To  the necessity of dilating  certain  contracted  parts of the
urethra, or that of incising its  meatus.
   x. To the inflammation of the ureters and kidneys, which is attri-
butable to the same causes as  the cystitis, and which is scarcely any
other than an extension of this last, but is usually fatal.
  y. To the peritonitis, of which instances are related by Dupuytren,
MM. Tanchou, Leroy, &c.
  z. To the instruments  having  got injured, or from  their having
been broken in the  organs, an accident which happened in cases  of
MM. Leroy. Heurteloup, Hervez and Maunoury, and which in more
than one  instance has rendered  lithotomy necessary,  or resulted in
death, as in the officer mentioned in the English Journals.
  aa. To the sinking and the  typhoid  state of the patient, whether
unaccompanied with  any apparent serious  lesions, or  whether pro-
duced by  purulent infection, which [typhoid state] is an accident that
has been  frequently observed, and which I  myself have witnessed
in  a certain number of instances.
  bb. To  the return of the disease, which was seen in  from 12 to 15
of the  patients of  M. Civiale,  in  France, and in nearly  the same
number among those who were  operated upon in England ; these
last have  been mentioned by MM. Chas. Bell, Liston, A. Cooper.
Key, &c.
  cc  To  the difficulties of the operation, which  are sometimes very
great, in consequence of the sensibility, small calibre  and diseased
condition  of the urethra or bladder, or  in consequence of the indoci-
lity or want of reason on  the part of the patient, as  for  example,
in children.
  dd. To  the total duration of the operation, which is generally from
six weeks to three months, and which may extend even  to six months
or a year.
  II. The  accidents and danger of lithotomy are especially ascribable :
  a. To the hemorrhage, which is infinitely more common and more
  vol. in.                     87 
690
NEW ELEMENTS OP OPERATIVE SURGERY.
dangerous than after lithotrity, and which is  explained  by the fact,
that a certain number of vessels are unavoidably wounded.
   b.  To the wounding of the rectum, either by incision or by con-
tusion, and which leaves a recto-vesical fistula as its consequence.
   c  To the peritonitis, which takes  place  frequently, and which is
almost always fatal.
   d.  To the urinary infiltration, and the inflammation of the cellu-
lar tissue of the pelvis, an accident which forms an exception in litho-
trity, but is verv common here.
   e.  To the phlebitis  and purulent  infection, which  are also more
common than after the broiement.
  /.  To the perforation of the bladder.
   g.  To the cystitis.
   h.  To the sinking of the patient.
   i. To the fistulas, which are caused by the wound in the perineum
or that  of the rectum.
   j.  To  the urinary and purulent infiltrations in the scrotum and
perineum, but which are quite rare.
   k. To the various kinds of erysipelas, which only occur as  an  ex-
ception, but which  are not unattended with  danger.
   /. To the  incontinence and impotency, which are scarcely more
frequent after lithotomy than after lithotrity.
   m. To the nervous symptoms, and which  may prove fatal.
   n.  To the pain, which is  acute but of short duration, so far as the
operation is concerned ; as  to the pain which is  subsequently  caused
by the wound and  passage  of the urine, it is scarcely of a more  se-
rious character,  than the  painful sensation in  the  urethra after
lithotrity.
   o.  To the return of the disease, which is almost impossible, except
by the formation or arrival of another stone in the bladder, inasmuch
as the surgeon  may satisfy himself directly,  both with the finger and
the instruments, whether there is anything more remaining in the or-
gan which he has just opened.
   p.  To the re-establishment of the course of the urine through the
urethra, which is sometimes delayed to  a long period.
   q.  To the necessity of keeping the  patient in bed during the space
tf 20 to 30 days.
   r.  To the necessity of a course of diet, or of quite a severe regi-
/men  during the space of from 8 to 15 days.
   s.  To the ureteritis, nephritis, orchitis, and collections in the pros-
tate,  which are not less common  here than after lithotrity.
   We perceive by this parallel, that all things being balanced, litho-
tomy and lithotrity have but very few advantages over each other,
in relation to the  pain, nervous symptoms, inflammation of the urin-
ary passages, incontinence and impotency,  perforations of the blad-
der,  and the sinking of the patient; that  the  exacerbations of in-
termittent fever, the mild or purulent form of the arthritis, orchitis,
abscesses in the prostate, lacerations of the urethra, pinching up of the
bladder,  infiltrations, external urinary deposits,  retention°of  urine,
 calculi arrested in the urethra, the necessity  of dilating or  incising
 this  canal,  and the danger  from instruments  that  have  become
 injured  or become  broken  in the organ, belong almost exclusively 
CALCULI IN THE KIDNEY AND URETHRA.
691
to lithotrity ;  that as a return of the disease may be caused by a por-
tion  of calculus overlooked in the bladder, it must be incomparably
more frequent after lithotrity than after lithotomy ; but that lithoto-
my, while  it  is more exposed to the risk of fistulas, lesion  of the
rectum and phlebitis, is rendered more especially dangerous by he-
morrhage, peritonitis, inflammation of the pelvis, and the necessity of
establishing a wound, which requires a repose and regimen foreign
to the habits of the patient.
  III.  From  whence  it follows, that provided the bladder is  sound,
the urethra free, the patient of no more  than  ordinary sensibility,
the  calculus less than the size of an egg, and of a moderate degree of
hardness, lithotrity is in  its aggregate  less  dangerous  than litho-
tomy.   Such is the formula which  I  supported in 1835 before the
Royal Academy of Medicine, and" which  I have no  reason  at the
present day to modify, whatever anxiety  may have been evinced by
a considerable number of busy-bodies to pervert it.   This language,
we will admit, scarcely corresponds with that of lithotritists, but I am
convinced  that it expresses the truth, and that after lithotrity has once
been  adopted into  the common domain  of surgery,  it  will find  in
this formula a more exact interpretation than it does in the ipse dixit
of its interested partisans.
                         CHAPTER  II.

         URINARY CALCULI EXTERNAL TO THE BLADDER.

           Article I.—In the Kidney  and Urethra.

                       § I.—Nephrotomy.

   Science  possesses numerous instances of calculi, which after hav-
ing become arrested in the kidney itself, have there acquired a con-
siderable degree of development, in such manner as  to ultimatelv
result in the death of the  patient.   From  hence came  the  idea  of
nephrotomy, which may be described as an incision into the  organ
through the  sound  tissues, or  the  incision of a purulent collection
over  which  we have  been  enabled  to  feel  through the lumbar
region; or it may consist also  of a simple enlargement of a renal
fistula, with the view  of favoring  the  escape or extraction Of the
foreign body.  It cannot be denied that it would be possible to reach
the kidney  on its posterior side, between the  last rib and the crest
of the ilium on the one hand, and  the  sacro-lumbar mass  and thei
posterior border of the oblique muscles on the other.   I have  many
times laid it bare by following this  process.   Though it be  next to
impossible to satisfy ourselves by any physical means of the  exist-
ence  of the  stone in the kidney;  though the reasonable  signs  of
this should be  deceptive ; though on the  other hand after the pre-
sence of the calculus is once established, it may still  be required to 
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NEW ELEMENTS OF OPERATIVE SURGERY.
know whether it occupies the entrance of the  ureter  or the pelvis,
rather than the tissues of one of the walls of the organ ;  whether
it  is or is not accompanied with ulcerations, and  purulent  dissolu-
tion, or any disorganization whatever; finally, though we  may be
forced to renounce nephrotomy, so long as there is no point exter-
nally which indicates the locality upon which we  should direct our
researches, it is also certain that  since the  labors of M. Rayer, the
diagnosis of calculi in the kidney is no longer a matter  of such dif-
ficulty, and that the presence of a tumor in the flank, with a prom-
inence in one of the lumbar regions, together with the signs of cal-
culous nephritis, would authorize additional essays in nephrotomy.
There is. moreover, no proof that this operation has  ever been  at-
tempted.  The  passage which is quoted from Hippocrates in support
of it, does not seem to have reference to it.  Nor can the opera-
tion, performed  upon the  free  archer, which has been  so much
spoken of, be deemed  any longer of any weight in a question of this
kind. What confidence in fact can we accord to  this  story, when
we see that Mezerai makes this criminal come  from Bagnolet, while
Pare, who relates the circiynstance from the chronicles of Monstrelet,
makes him come from Meudon; when some authors  state  that he
lived under Charles VII., and others  under Louis XI.  ; when Collot
and the  author  of the History of France believe  that  nephrotomy
was performed upon him, while Rousset and Sprengel suppose that
he was cut for stone by the high operation; when Mery, on the con-
trary, considers that he was cured by the  perineal operation, while
Toilet asserts that the only operation  performed upon him was mere-
ly gastrotomy  for a  volvulus ?  The case  of the consul  Hobson
(Transact. Phil. Abr., vol.  IV., p. 116,) who is  stated to have been
operated upon by Marchettis, is hardly more conclusive.  Bernard,
who relates it, had no other proof of the  fact than the  assertion of
the patient and  his wife, while Marchettis  himself, in his Observa-
tions Rares, says not a word of it.  It is  to be hoped  therefore  that
the discussions  raised in the schools  of surgery in 1754, by  Mas-
quelier and Bordeu, and by Cousinot  a century before,  to ascertain
whether nephrotomy was or was not practicable, will not again be
revived.   The operation cannot, in reality, be  proposed, except in a
•mall number of cases, as  in those in which  the flank, which has
become  the seat of  an  evident fluctuation, after  the existence of
various  signs of calculous affections in the kidney,  would ena-
ble us to reach the morbid  collection with facility and certainty ; or
in those cases also  in which a fistulous ulcer should have enabled us
to come into immediate contact with the stone by means of an ex-
ploring instrument; or finally, where the  calculus  itself projects at
the exterior, and may be recognized through  the  integuments.  In
such cases the operation is so simple  and  is reduced  to so small a
matter, and has moreover to be modified by so many controlling cir-
cumstances, that it would be useless to describe it in detail.   All that
can be said is this, that after having  made openings of sufficient ex-
tent, or enlarged those which already existed, by means of the bis-
toury alone,  or by this instrument  guided upon  the director, we
should search for the stone with caution, and in order to  displace' and
extract it, make use either of the ordinary forceps, the polypus for- 
URETHRAL CALCULI.
693
neps, hooks or scoops, or the dressing forceps, or the  fingers alone.
Lafitte, (Mem. de VAcad. de Chir., t. II., p. 170, 1819,) has very ju-
diciously described the cases which may require  this operation, and
it might probably have been performed with advantage upon the pa-
tient mentioned by Billebaut, (Acad,  de Berlin, t. IV., App., p. 32.)
I have attempted it upon two calculous  patients, and in both instan-
ces confined myself to the first stage, that  is to say. that I  stopped
after making an opening into the vast lumbar  abscess, and that  the
patients then finding themselves relieved, would no longer  listen to
an operation.

                       § II.—Ureterotomy.

  What I have said of calculi arrested in the kidney is applicable
with still greater force to calculi lodged in the ureter.   Though they
might be retained in any part of the course of this duct, it is however
in its upper third and  near its vesical  extremity that  they are most
frequently encountered.  In the first position they may ulcerate the
ureter, pass partially into the cellular tissue of the flank, and produce
in that part an abscess which may, if necessary, be opened above the
crest of the ilium, or this abscess may of itself open through this region.
A patient who died almost suddenly, in 1831, in my department at
La Pitie,  presented to  us a remarkable case which the reader will
not  perhaps be  displeased to  find here.   The kidneys  were  per-
fectly sound, as well  as the left ureter and the bladder, which con-
tained no stone ; but the  right ureter, which was  greatly dilated as
far as to three inches below its origin, was  perforated  posteriorly by
a calculus the size of a nut, which projected into its cavity, and made
a prominence externally at the  bottom of a purulent collection under
the ascending colon.  This calculus contained a pin in  its centre,  and
appeared  to have caused the thickening,  induration,  engorgement,
and  suppuration in the cellular tissue and muscles, which,  from the
kidney to the bottom of the pelvic  cavity,  spread  to such extent as
almost to close up entirely the  lower strait of the  pelvis.   It is very
certain, as  I satisfied myself upon the dead  body, that this  stone
might have  been  readily extracted by the flank on the  same side.
But  who could have ascertained the certainty of its existence during
the life of the patient, and who upon the strength  of  mere supposi-
tions would have had the boldness to perform the operation required ?
The  stone which  M. Iliff (Bull, de Fer., t. III., p.  287,)  extracted
through a fistula in the right groin,—had it escaped from the bladder
or the ureter ?

                Article  II.—Urethral Calculi.

            § I.—In the Tissue of the Vaginal Septum.

  Should  a calculous  concretion have  developed  itself between the
urethra  and vagina, an instance of which has been related by M.
Macario, and should it.have been  possible in any manner whatever
to have established its presence, its extraction  might be effected by
incising through the  vulvo-uterine passage, and to the  extent  re- 
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NEW ELEMENTS  OF OPERATIVE SURGERY.
quired, the entire thickness of the cyst which should separate it from
the urethra.
                    § II.—In the Prostate.

   The gland which surrounds the  commencement of the urethra
pite frequently suppurates and ulcerates.  The urine may become
effused to a certain extent in the cavities thereby produced, and as
in the patient of M. Lizars, (Encyclogr. des Sc Med., 1836, p. 140,)
deposite there small calculi which may acquire more or less consid-
erable dimensions.   In  other  cases the calculi  become arrested and
lodged exclusively  in  the  natural  dilatation  of  the  canal which
contains them.  These  calculi may  either  be pushed back into  the
bladder, or seized with a sheath forceps  and extracted, or may be
broken up in fragments and destroyed  in the place which they oc-
cupy.  The others, on the contrary, cannot be  reached or  seized
through the urethra but with considerable difficulty.   It is  through
the perineum that we are obliged to cut down upon them.  The
same is to be done for those which, as Dupuytren has remarked, (Bull.
de la Fac de Med.,  t. VII., p. 136,) are sometimes developed in  the
tissue of this region, whether, as has been noticed by M. Jacquier,
(communicated  by the author, 1839,) after an operation for lithotomy,
from some fragments having been left in the wound, or that a small
calculous  mass may  have escaped into  the  surrounding  tissues
through a laceration or ulceration in  the urethra.  The patient is to
be placed in the same way as  for perineal cystotomy.  After having
introduced the catheter, provided there should have been no obstacle
to it, we again endeavor to  ascertain by means of the finger  the
actual position of the stone.   The operator then cuts down upon it
and lays it  bare.   Should the first incision not appear  to be suffi-
ciently extensive, he enlarges its dimensions by  reapplying at  its
angles the instrument first employed, but now guided upon a grooved
sound.   After this the means of extracting the  calculi consist of the
forceps, tenacula, fingers  or scoop.  On this  subject  we may con-
sult the memoir of Louis inserted among those of the Academy.

                    § III.—In the Urethra.

  Calculi have been met with in every part of the excretory duct of
the urine, in which duct, however small their  size may be, they soon
give rise to the occurrence of accidents.  When behind the meatus,
where Bernard (Trans. Phil. Abr., vol. IV., p. 109) has met with
them in two instances, or when they are in the fossa navicularis, where
I  have frequently seen them, it rarely happens that the efforts  of the
bladder and the volume of the urine will not be  found sufficient to
expel  them.  Upon  the supposition however that it should be other-
wise, we should proceed  to search for them by the dressing forceps,
the point  of which is  somewhat concave  and  flattened •  or  as
Sabatier recommends, by gliding underneath them a noose of iron or
brass wire;  or by means of a small  scoop shaped  like a hook,  and
which M. Civiale used on Boisseau in September, 1828 ; or finally, if
these should be attended with too many difficulties, by incising the
lower wall of the urethra in front of the stone, by means of a narrow 
URETHRAL CALCULI.
695
bistoury introduced into the interior of the canal and brought from be-
hind-forwards, unless we should prefer making use of a kind of conceal-
ed bistoury known under the name of uretrotome.  An indispensable
precaution, whatever may be the process we adopt, is that  of fixing
the penis firmly with the forefinger and thumb placed behind the cal-
culus, in such manner as to be enabled to favor the expulsion of this
last, or at least to prevent it from escaping  backwards from  before
the instrument.  The forceps, which has been employed with success,
and the  manipulations  so  much  extolled by M. Polh of Moscow,
(Gaz. Mid.% 1839, p. 168,) possess no peculiarity which has not been
already essayed by others.   The articulated scoop of M. Leroy, (Rev.
Aled., 1835, t. IV., p. 118,) either simple or with a sheath, together
with the respective forceps of Hunter, Ravaton, or Weiss,  and  also
aspiration, either by means of the mouth or in any other manner, as
had already been mentioned by P. Alpin, would be suitable in these
cases as well as in those which will be mentioned farther on.  A dis-
secting forceps terminating in claws would succeed still better, should
the calculus be small and be situated at less depth than two inches.   I
have used it with advantage in five instances. M. Wigan, (Encyclogr.
des Sc'. Med., 1839, p. 273,) with the view of dilating the urethra in front
of the calculus, in the case of a child, employed with advantage a forced
injection.  When the stone is arrested in the commencement of the cor-
pus spongiosum, the surgeon also commences by securing its posterior
portion by means of one of his hands, and then endeavors to draw it
towards him by means of the noose of Sabatier or Marini, in the way
it was employed successfully by M. E. Rousseau.  If this should not
answer we have recourse to the  sheathed forceps, the branches of
which being dentated, slender, resistant and concave, do not separate
until they arrive at the anterior side of the calculus, as if for the pu«-
pose of dilating the urethra and to cause  the  foreign  body, wheti
pressed upon by the finger, to lodge itself between them with facility.
M.  Civiale,  in order to  be certain  that  the forceps  is  properly
placed, and not to expose to the risk of shutting it up  uselessly,
recommends that it should be explored by a  stylet, the head of which
separates the branches apart while it is being withdrawn towards the
sheath.   By means of this stylet the operator finds  out where the
calculus  is and displaces  it, even if  it is not  properly seized, and
incurs no danger of wounding the patient.   When it  is once firmly
grasped it is to be extracted, taking care to  proceed with gentleness
if it is somewhat large, and in such manner as to cause not the slightest
laceration possible.  When the calculus  has  established itself in  a
cul  de sac on one side, it may convey the idea of a contraction of the
urethra, and cause its extraction to be  attended with serious  diffi-
culty.  A patient who was sent to my care from Guadaloupe, and who
had suffered during the space of ten years,  and undergone all kinds
of treatment without any one ever having been enabled to penetrate
into the bladder, and who urinated only in  a very fine stream, was
immediately cured as soon as I had extracted from the membranous
portion of the urethra a calculus  of the  size of a small  green pea.
Should its volume have rendered its extraction difficult, which is  a
rare occurrence, inasmuch  as  its  presence in  the  urethra could not
have existed a sufficient length of time to have sensibly increased its 
696
NEW ELEMENTS OF OPERATIVE  SURGERY.
size, we should have recourse to broiement, or should traverse it. by
means of a perforator introduced in the place of the stylet, in  order
afterwards to break it down with greater facility.
  A calculus mentioned by M. de Renzi, (Gaz. Med., 1834, p. 538,)
and which was two inches  long and a half an inch thick, and which
surrounded the bulbous portion  of the urethra, could not be extracted
until an,,incision was made into the tissues, and after the stone had
been broken up.  Calculi also that become arrested  in  the  bulbous
portion should be treated  upon the same principles.  It is evident
that we should experience  more difficulties in the membfanous por-
tion, in which part, however, they are most  frequently lodged.  If
the preceding attempts, which could be  modified by making use,
for example, of a curved forceps, should not  succeed, and if the ac-
cidents were alarming, an  incision into  the  urethra would be  the
only remedy.  The same may be said in respect also to all the cases
which have just been described, and for which extraction or broie-
ment constitute only the first means to be made trial of.   Who could
otherwise than by an incision, extract a calculus developed in  the
urethra around a brass ring, as in the case of  M. Liston, (Arch. Gen.
de Med., t. I., p. 268 ;)  or a calculus which should have acquired an
inch and a half in diameter in the fossa naviculars, as in the patient
of M. Schwartz, (Bull, de Fer., t. XIV., p. 204) ?   When the neces-
sity of an incision  has become apparent, the following is the mode
in which we should proceed.  Should the  stone occupy the second
portion of the urethra, it is necessary that  an assistant should keep
it fixed  at  this point by  means of two fingers  introduced into  the
anus.  The surgeon with a straight bistoury divides the integuments,
which have been previously stretched, then  the cellular tissue and
all the parts contained in the base of the recto-urethral triangle, and
finally in this  manner comes down upon  the foreign body.   After
having sufficiently enlarged the incision, he extracts  the calculus by
means of suitable instruments, and  for fear  that other calculi may
exist in the bladder, or in the  prostate, or in the remainder of the
urethra, he explores  all these regions with the grooved  sound, or  a
female or any other catheter.   Behind the scrotum the envelopes of
the corpus  spongiosum of the urethra are  so movable that their
division in  general is attended with considerable difficulty.   It is for
this reason that it is advisable to  introduce  down to the stone and
through the natural passage a  strong grooved sound, then  to raise
up  the scrotum as much as  possible, to stretch  the tissues carefully,
to have the calculus secured by the fingers of an assistant behind it,
and to give to the incision of the integuments a much greater extent
than to that of the urethra  itself.  All this  must be done in  the first
place, to reach the foreign body with greater certainty, and secondly,
to prevent infiltrations.   The same course should be adopted in re-
spect to calculi in front of the scrotum, with  this difference, that the
scrotum should in that case be pushed back towards  the  anus.  It  is
important in these different cases to open the urethra over the stone
only in  one point, and afterwards to enlarge this incision upon the
grooved sound, either in front  or  behind.  If  we pursued an oppo-
site course we should have a contused wound with fringed borders,
but little favorable to cicatrization ; while the process recommended 
LITHOTOMY--LITHOTRITY.
697
furnishes one which is regular, and the best possibly adapted if not for
immediate reunion, at least for a union that is sufficiently prompt.  As to
the advice of Philagrius,  (Peyrilhe, Hist, de la Med., p.  701,) who
recommends, with the view of avoiding fistulas, that we should open
into the urethra upon the  dorsal surface of the penis, it could not be
applicable at most but to  small calculi arrested in front of the scro-
tum, and cannot, as I conceive, be revived again under any title.
Moreover, is it very certain that Philagrius intended to speak of cal-
culi and  opening into the urethra, rather than of calculi and opening
into the bladder ?  Fistulas are much less frequent after the urethral
incisions, which I have just described, than would  be imagined.   M.
Civiale relates the history of a patient who was operated upon at La
Pitie by  an  interne of that hospital, and who had three  large  sized
calculi in the  urethra, viz. in the bulbous, membranous and prostatic
portions.  The operation  was protracted and laborious, and left an
irregular wound ; nevertheless  it was not followed by fistula.  It is
true, however, that this wound will sometimes remain fistulous, and
that its cicatrization in certain cases is attended with great difficulty.
In a patient operated  upon in September, 1838, at the  hospital of
La Charite,  and in whom, however, there was only a very small cal-
culus in the  bulbous portion of  the urethra, the fistula notwithstand-
ing still continued for the space of five months.
  E. Between the glans penis and the prepuce.—Children are quite
liable, as we have elsewhere said, to a contraction of the prepuce,
which part in them is naturally very long.   It results from this  that
the urine  is  effused there as it  were into a sac, in coming out from
the urethra,  before making its escape externally, and that there will
be  formed here quite frequently calculous concretions, which have
been noticed also in adults, though more rarely.  They may acquire
a volume which is  really  astonishing.   Morand  preserved a speci-
men of one  which was almost as large as an egg, and which had on
its upper surface a little gutter for the passage of the urine.  Saba-
tier had in his possession  a similar one which was still larger.   The
extremity of the  penis  in  such  persons becomes swollen and heavy,
and usually pendant like the  clapper  of a bell.  The extraction of
such calculi is an  easy  matter.  All that is required  is to intro-
duce between the prepuce and the foreign  body a grooved sound,
upon which  we conduct a straight bistoury which incises and divides
the tissues from within  outwards.   We  might also incise them from
without inwards by coming  down  perpendicularly upon the stone.
It was  an operation of this kind which made so much noise in Swit-
zerland at the commencement  of the last century, and which was
given out by some persons as a case of supra-pubic lithotomy.

                 [LITHOTOMY—LITHOTRITY.

  Lithotomy preceded by partial lithotrity.—The first operation
of lithotomy ever performed in  China, was,  according to our coun-
tryman, Dr.  Parker, (see a memoir by him entitled Notes of Surgica
Practice amongst the Chinese, in Cormack's Monthly Journ., Edinb.»
June, 1846, p. 393, 394, &c.,) that which was performed by him about
the year 1844, at Canton,  upon  Si-Yau,  a resident of that city, aged
   vol. in.                     88 
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NEW ELEMENTS  OF OPERATIVE SURGERY.
35.  The stone was first  crushed by a lithotritor about a year be
fore, and was now extracted in two  fragments  by the lateral opera-
tion.  They weighed  together one ounce  and a drachm,  and mea-
sured b\ inches in their united circumference one way, and  3£ the
other.   The patient was well on the 18th day.  The success of the
operation produced a great sensation among the Chinese.
  Dr. Parker afterwards performed the operation of lithotomy in the
course of the years 1844 and 1845, upon the following  among other
Chinese: Hissecond case was Chau Wei, aged 21, 2 stones, one an
ounce and the other one drachm.   The rectum wounded, which in-
duced the surgeon to divide the sphincter immediately.  Notwith-
standing this and the  presence of large worms in great numbers in
the stomach and alimentary canal, and the  consequent irritability,
the young man finally recovered perfectly, with only a small fistula
in the urethra.  Third case, Lui Kwan, aged 34, had had calculus for
23 years.  Operated upon May  13, 1845; stone about 5 inches  in
circumference, and weighing 2\ ounces.   The patient  exhibited un-
paralleled fortitude, scarcely  appearing to notice the incisions.   The
calculus  was smooth,  spheroidal, and  of chocolate color.  Though
but a few ounces of blood  were lost during the operation, a sudden
movement of the patient on the  9th day,  brought on considerable
hemorrhage, yet  the  cure was complete by  June 6th.  Fourth, Hu
Pin,  aged 28.   The  stone, which was 4 inches by 3 in circumfer-
ence, and weighed 5  drachms, was extracted by Dr. Parker, June
18, 1845, by the lateral operation.   It was of the mulberry variety,
with a surface as rough as sand-paper, showing brilliant minute crys-
tals under a strong light.   Like other Chinese, says Dr. Parker, this
man acted most heroically, uttering  no complaint, and smiling when
the stone was shown to  him.   The next day additional fragments
were removed.   Though severe reaction  ensued and continued for
several days, the patient was discharged cured on August 3d.
  As hemorrhage in perineal lithotomy constitutes the cause of  one-
fourth of the fatal terminations by this process, it is, as M. Begin re-
marks, important  to devise some efficacious means for  arresting  it.
Deeming its source, from its slow exuding character, to be in a pre-
ternatural enlargement of the arterial capillaries in the perineum and
vicinity of the bladder, he has suggested, where ligatures and torsion
cannot be used, and has in two instances  eminently succeeded  by a
process  which consists (Arch. Gen. de  Med.,  3e ser., t.  XIII., 1842,
p. 372) in maintaining, by means  of a gum-elastic syphon, a contin-
ued current of cold water in the wound.
  Supra-pubic lithotomy was recently  successfully performed by M.
Segalas (Arch. Gen., Oct. 1844, p. 250) on a  man who had been af-
flicted with stone from his childhood, but during an interval of 22
years experienced no inconvenience  from  it!   It  weighed 107
grammes.
  A new process for supra-pubic lithotomy.—-In the same way as we
deem ourselves bound to give circulation in an elementary work of
this description, to every new suggestion that may appear to be ra-
tional, we feel equally under a conscientious  obligation to condemn
in unequivocal terms whatever carries on the face of it positive error
or harm, especially where it emanates from names justly possessing 
LITHOTOMY--LITHOTRITY.
699
a high authority.  Such we consider the process of supra-pubic litho-
tomy, in two stages, again revived  by M. Vidal de Cassis, (Arch.
Gen. de Med., 4e ser., t. III., pp. 219, 220,) and this to be performed,
not by the bistoury, but by the tedious, successive, painful and danger-
ous applications of  Vienna paste and chloruret of zinc, gradually in-
flaming the tissues,  in order that they may consolidate, and thus pre-
vent urinous  infiltration, after the bladder is opened into !
  Lithotrity.—Dr.  J. Randolph, in addition to several other cases of
lithotrity, recently, it is  stated, performed this  operation (Amer.
Journ. of the Med. Sc, July, 1846, p. 263, &c.,) on a  man aged 30,
with  complete success;  having effectually crushed, pulverized  and
brought away the stone in four sittings, of a few minutes each, during
the space of a month, and without  any pain to the patient.  He used
Heurteloup's percuteur, and also a modification of  this.
  M. Leroy  d'Etiolles has lately laid  before the Paris Academy of
Sciences, (sitting of April 27,  1846, Gaz. Medicate de Paris, 3e ser.,
t. I., May .2,  1846, p. 354,) a  memoir describing a new set of litho-
tritic pulverizing instruments, (pulverisateurs oscillants,) and  a new
process which he has been in the practice of for the  last  two  years,
by  means of which, \vhere the stone is alone, and of  large  size, he is
enabled, by making a lateral oscillatory movement, which presents
the instruments successively upon all the points  of  the  calculus, to
crush it into powder in a few minutes.  The instruments consist of
rasps,  blades, &c.  When the  stones are numerous  and  small, he
continues to  use  the method of  ecrasement, which he  has  now em-
ployed successfully, it is stated, in over one hundred cases.   This
last method is made more effectual by associating with it artificial ex-
traction.  By means of a stone-breakei (brise-pierre), with  large and
deep scoops  (cuilliers), he is  enabled, every time  he withdraws the
instrument, to extract nearly two millimetres, cubic dimensions, of de-
bris of calculus ; so that under favorable circumstances, a calculus of
35 millemetres  of diameter, (15 lines,) may be broken up and remo-
ved at a single  sitting.  M. Heurteloup read  at the  same sitting a
memor on the immediate pulverization and extraction of calculi, in
which he states that he has succeeded in  a great number of cases, in
effecting immediate and complete extraction of fragments of the stone
through the natural passages, frequently in much shorter time than
would be required by lithotomy.  His reasons  in  favor of this new
modification,  rather than  leaving the  expulsion  of the  fragments to
nature,  are:  1, because in simple  breaking of the stone, there  is a
chance that the fragments may be  lost in the bladder; 2, because the
broken fragments too  frequently get lodged in the neck of the bladder
or in the urethra, giving rise to serious accidents, and requiring sub-
sequent operations much more painful and difficult  than the principal
one; 3, the fragments, if left, may give rise to catarrhal  inflamma-
tions of the bladder, which may endanger life; 4, in quite a great
number of patients, the simple  breaking up  of the  stone  would be
injurious unless there was some mode of immediately extracting the
fragments; and 5,  because the  membranes of the  urinary organs,
when inflamed, are  liable to make large deposits of phosphate of lime.
Inflammation, therefore, should, as  far as possible, be excluded from
this operation.   His percuteur courbe a marteau, so much extolled 
700           NEW ELEMENTS  OF OPERATIVE SURGERY.
 by Sir Philip Crampton, (see Dublin  Quarterly Journal of Med.
 Science, Feb., 1846,) as preferable to any other lithotritor, is the in-
 strument upon which  he chiefly relies.  By this  powerful instru-
 ment the stone is seized between two planes, one of which is render-
 ed immovable by its connection with  the fixed support, while the
 other is movable   By recent modifications he is enabled to measure
 with accuracy the size of the stone to be extracted, and  to  reduce
 it to the diameter of the two approximated scoops (cuilliers), that is,
 to the diameter of the urethra itself.   Percussion is the great  feature
 of his new method, and he effects the  closure of the scoops by the
 hammer, in the same way that he breaks the  stones with his percu-
 teur.  But the use of the hammer requires a  point d'appui, in order
 to keep the instrument which  holds  the stone  fixed and immovable,
 and  which latter, from being movable, also becomes fixed and immov-
 able.  Now  this point d'appui exacts an apparatus to support it, and
 in which it may be moved, and become instantly fixed or movable at
 pleasure.   He effects this by means  similar to those which he  has
 long  since made known, under the names of point fixe and  lit rec-
 tangle, but in which he has made several important modifications.
   M. Deleau, also, at the same sitting of the Academy, broached a
 new process for lithotrity, which consists in introducing into the blad-
 der a sort of artificial pouch or bladder, in which he causes  the cal-
 culus to enter, and in which this latter is then broken up and pulver-
 ized by  the  ordinary  instruments, or  submitted  to  the action of
 chemical agents,  without any danger  of wounding the organs.
   M.  Taroni, of the department  of the Aude,  France,  relates a
 recent case which is calculated to inspire farther dread in the applica-
 tion  of a severe crushing force to  lithotritic instruments.  After
 succeeding in nearly crushing up  a  stone  of 32 millemetres diam-
 eter with  one of Charriere's  No.  2 stone-breakers,  (Journ. des
 Conn. Alid.-Chir., Mars 1, 1846, pp. 101, 102, 103,) he found, after
 the fifth time of fracturing the  pieces, and during which he made no
 false or stronger movement, that he  could not, to  his utter dismay,
 withdraw the instrument.  He however succeeded  in getting the
 broken branch lodged  in the perineal  portion of the urethra, from
 whence he  succeeded  in effecting its removal from  the bladder.
 This is a serious warning in regard to the selection of instruments,
 when the processes most in  vogue require, as  we perceive, a great
 augmentation of crushing power.
  Lithotrity in children.—Though lithotrity, for the various reasons
given in the  text by our author, cannot be conveniently applied to
children, or at least was thought to be obnoxious to persons of this
period of life at the time M. Velpeau wrote, some doubt  may perhaps
 be expressed  in  regard to that judgment in  the  present more
advanced state of this new mode of relieving calculous patients.  M.
Segalas exhibited to the Royal Academy of Medicine, Jan 4 1841
(Arch. Gin. de Med., 3e ser.,  t. XIII., 1842,  p.  243,)'  a child two
years of age, from whom he had extracted, by  broiement, a stone of
considerable size, in twelve sittings.   The stone guaged fourteen to
fifteen  lines of diameter.  Other successes of the same  kind  induce
M. Segalas to consider extreme youth no exclusive objection  to the
process in question. 
LITHOTOMY--LITHOTRITY.                  701
    A new lithotriteur has been invented recently by Dr. Arthault of
 Paris, by which  it is stated (Lond. Med.  Gaz., May, 1846, p. 843)
 that a stone of the size of a pigeon's egg was crushed up into an im-
 palpable powder in  the  space of three minutes, the operation  being
 performed on the dead body at the hospital, in the presence of several
 surgeons !
    Statistics  of Lithotomy and Lithotrity.—Dr. Wm. Keith (Edin.
 Med. and Surg.  Journ., vol. LXL, 1844, p. 123) furnishes one  of the
 most impartial and  lucid  tables  we have  seen of the comparative
 merits of lithotomy and lithotrity.  Out of 23 cases of lithotomy and
 16 of lithotrity operated upon by him  at the Royal Infirmary of
 Aberdeen, Sco'tland, between March 20, 1838, and March 20, 1843,
 there were among the former 1  death in 11^-, and of the latter 1 in
 \5.   The average time of treatment of the first was  60f^ days, and
 in the second 44|.   The average age in the first 56^, in  the second
 56^.   The  average weight of the stone in the first  8 dr. 14 gr., in
 the second 3 dr.  8 gr.  Out of 19 of the cases of lithotomy aged from
 50 to 78, only one died.  In the  ten years  Dr. Keith has  practised
 lithotrity, no accident of any kind has ever occurred to him.  He
 dispenses with many of the instruments and with injections of the
 bladder.   He  has usually however selected the  best subjects  and
 small stones  for lithotrity.   Out of 42 cases of stone, the whole num-
 ber received in the years mentioned, only one was a female!
    One of the latest statistical tables on lithotrity, furnishes yet more
 favorable  results for this operation than  the  general text of the
 author.  M.  Cazenave of Bordeaux, at the sitting of the Paris Royal
 Academy of Medicine, Nov. 11, 1845, (Arch. Gen., 4e ser., t.  IX.,
 Dec, 1845, p. 496,) gives as the result of 52 operations by lithotrity,
 in his practice in the last 15 years, 43 cures and 8 deaths.   One only
 continued  to suffer after the operation, though two large calculi had
 been  removed from him.  Of the  8  deaths, this result  in 3  was
 caused by circumstances foreign  to the operation.
    New Process for  Extracting the Stone from the Bladder.—Cys-
 tectasy or lithectasy,  so called, being a name given to a new process
 proposed by  MM. Jno. Douglass, Dr. Wilson, Mr. Thos. Elliot, &c,
 (see Edinb. Med. and Surg. Journ., January, 1843,) and which con-
 sists of crude, painful attempts,  persisted in  at  the  hazard of the
 patient's life for 24   hours, at  dilatation, by introducing  through a
 small wound  in the perineum and  membranous portion of the urethra
 a distensible pouch into the bladder, which is to be filled with  liquid
 and left there, is one of those daring and irrational attempts to revive
 an obsolete practice  which must be generally reprobated.
    Chemical action on urinary calculi.—In  the opinion of MM. Pe-
 louze and Gay-Lussac, (see their report on the communications of M.
 Leroy d'Etoilles,  Arch. Gen. de Med., 3e ser., t. XIII., pp. 502, 503,)
 acid and alkaline chemical re-agents act but very  feebly on urinary
 concretions, and  chiefly on their uniting  animal   matter.  Besides
 which, this reaction  itself may give  rise to new concretions, in con-
 sequence of  the  saturation of the free  acids,  or  acid  salts of the
 urine.   Neither in drinks, baths, or injections, can they be  of great
• efficacy, and moreover in the last form are  dangerous, though they
 Would have, however, in association with lithotrity, the advantage, 
702
NEW ELEMENTS OF OPERATIVE SURGERY.
from the calculus being  broken into fragments, of allowing the  in-
jected chemical solutions to act on a far greater extent of surface.
  Gastric juice has been proposed as a simple solvent of calculi.—
We are not aware that the suggestion of M. Millot, to  inject dilute
gastric juice, (i. e., diluted  with an equal volume of tepid  water,)
where lithotritic crushing instruments have failed, has ever been car-
ried out in practice.  M. Millot found (Arch.  Gin.,  t.  III., 4e ser.,
p. 361) this solvent had a powerful disintegrating effect even  upon
the surface of mural calculi, which had resisted every kind of instru-
ment.  The idea of dissolving calculi by injecting chemical (not sim-
ple) solutions, had long since suggested itself to  Fourcroy.  Upon
this principle it was, that Mr. S. E. Hopkins, (see Transactions  of
the Royal Society of London, 1843, Part I.  ; also Arch. Gen. de Med.
de Paris, 4e ser., t. III., 1843, p. 103—105,) availing himself  also  of
the well known fact of the affinity of lead for the phosphates, and of
the common practice with country people of  drinking hard  cider in
gravelly  complaints, instituted  a variety of  experiments, the result
of which  was, that a mild  combination, which he  calls nitro-sac-
charate of lead, had a sensible effect in dissolving  portions of calcu-
lous phosphates, and precipitating them under the form of phosphates
of lead.  Injected into the bladder of sheep, the solution  of this com-
pound produced no unpleasant effects.
  Urinary calculi, according to M. Civiale in a late work, (Traite-
ment Aledical and Preservatif de la  Pierre et de la Gravelle, Paris,
1840,) may alternate with each other.  Thus cystine maybe formed
at one time, and  the other principles of the urine at another.   So
uric acid  and the  oxalate  of lime.  This  may occur without any
known cause or change  of food  or  medication.   Hence, according
to the experienced author, the doubtful efficacy of medicines directed
against this or that calculous diathesis.  Stone and  gravel, moreover,
may co-exist simultaneously.  Here there must be a more profound
lesion of the urinary function, so that after the breaking up and extrac-
tion of the stone, the gravel will, by aggregation, reproduce another
stone, a certain lapse of time after the operation,  thus often leading
to serious misapprehensions.  It is of the utmost  importance, there-
fore, in cases of gravel, or its persistence, that the exploration should
be extremely minute.    Contrary to M.   Segalas and  others,  M.
Civiale considers a particular attention to the instrument to be used
a matter of importance,  and for this purpose  recommends, where
gravel is in too large  concretions to escape by the urethra, that we
should make use of the lithoclast, as modified, in order to ascertain its
actual morbid condition.   In atrophy of the bladder we  must recur
to the  trilabe.  It is therefore a matter of great moment to resist if
possible the formation of such  gravelly deposites or sediments,  by
some  conservative course of medical treatment, if any such exist.
The   red sand and pulverulent deposites,  constitute,   M.  Civiale
thinks, the first stage of gravel.   This may  be induced' by  a preter-
natural excitement of the kidneys, caused  perhaps by some  morbid
condition of some portion of the apparatus ;  thus,  contraction of the
urethra, or a spasmodic closure, or neuralgic state of this canal or of
the neck of the bladder.  Hence, the utility he has found in cupping, •
leeches and emollients to the kidneys, general baths, copious use  of 
LITUIOTOMY--LITHOTRITY.
703
drinks that are slightly diuretic, certain  mineral waters, and purga-
tive medicines in divided  doses.  In the gravel of uric acid, the
most common of all, M. Civiale classifies the disease  under three
varieties:  1, emission of gravel spontaneously and without  pain;
2, nephritic colics with emissions of gravel;  and 3, nephritic col-
ics without expulsion of gravels.  The disease in these, and also in
the forms  of cystine, oxalate of lime, and  of white or phosphatic
gravel, may go on in spite of the medical treatment, and then  the
difficulty  may arise  from  some morbid state which paralyzes  the
efforts of nature and  of art.   Thus, the gravel may not be  enabled
to make its escape, because it is retained in  the kidneys or  ureters,
or in the bladder.  In the last mentioned, this retention  may be
caused : 1, by a spasmodic contraction of the urethra or  neck of the
bladder; 2, by one or more contractions in  the deep-seated  portion
of the urethra; 3, by  a tumefaction or other disease of the prostate;
and 4, by a paralysis of the  bladder.  Age, sex, climate, and food,
have also a great  influence on calculous affections.  An important
point is, that M. Civiale pronounces decisively  against the prevailing
opinion in relation to  the influence of nitrogenized food in the pro-
duction of gravel and stone.   He wholly rejects all attempts at cure
by chemical remedies, either internal  or external, and especially by
alkaline preparations.
   Urinary calculi.—The number of urinary calculi preserved in the
museum of Guy's Hospital, and which, as given by Dr. Marcet about
30 years since, amounted to 228, had in April,  1842, (see Guy's Hos-
pital Reports, April, 1842,) increased, according to Dr. Bird, to 363.
Of these : 245 have for their  base uric acid ; 17, urates  of ammonia
or of lime'; 45, oxalate of lime;  11, cystic oxide; and 21, earthy
phosphates.
  Mr. Syme, in a woman aged 75, who had suffered from urination
for 20 years, found on examination a stone  which had  occupied a
distinct pouch  between the urethra and vagina. There was an aper-
ture into the  pouch from  the urethra, through which the  morbid
cavity was laid open along the whole extent of the urethra, and upon
the stone, and  without wounding  or  opening into the vagina.   The
calculus was oval, and an inch and a quarter  long, and the womarf
rapidly recovered.   (See Cormack's  Monthly Journ., Edinburgh,
Feb., 1846, p.  83.)  T.] 
704     .     NEW ELEMENTS OF OPERATIVE SURGERY
    PART  EIGHTH.

DISEASES OF THE URETHRA.
                         CHAPTER I.

                         CATHETERISM.

  Catheterism is resorted to for the purpose of giving  egress to the
urine, for exploring the bladder, and for the cure of certain diseases,
and  to  aid in the success of certain operations.   The instruments
which it requires, and which have been for  a long time  known under
the name of catheters, which they still retain to a very considerable
extent in England and in Germany, are more commonly designated
in France by the title of sondes or algalies; this last word, however,
is only applied to hollow tubes of metallic composition.   Stems that
are solid, cylindrical, conical or blunt-pointed, and of various  sub-
stances, may  also be employed for this purpose.  The name of cath-
eter  is no longer applied [in France] but  to the grooved instrument
made use of  in the operation of infra-pubic lithotomy.   The object
of the surgeon  being that of penetrating into the  urinary bladder
through its natural outlet, a knowledge of the urethra is an  indispen-
sable preliminary, without which catheterism  would expose to  the
risk  of the most  serious dangers.   (See  my Anatomie  Chirursical,
1827, t.  II.)

  Article I.—Examination of  the Methods and Instruments,

  Whether catheterism be evacuative, explorative, conductive, direc-
tive,  or  derivative, as M. Roux denominates it, it  is in  general  per-
formed in all  cases according to the same rules.

                              §1.

  Copper catheters,  (sondes  en cuivre.) which  were formerly made
use of, and which had the inconvenience of oxydating and becoming
covered with verdigris, are universally replaced by silver catheters,
(algalies.)  The fragility of glass catheters as proposed  by M. Zavi-
ziano, would  incur the risk of too much  danger for any person  to
venture to make use of them.  Flexible catheters made  of horn,
leather, or metallic spirals, having  been  contrived or used only for
want of better, must also remain in the oblivion into which they have
fallen since the  invention of  elastic catheters by Theden, Pickel and
the watchmaker  Bernard.   Catheters of silver or those of tnaille
chart, and those of gum or  ivory that are flexible, are  therefore the
only ones which deserve to  -be retained; the first for those cases
which  require  solidity and where the instrument is not to remain
more than a few minutes in  the organs;  the second for those cases
where, after the operation, it is desirable  not  to withdraw them im- 
          EXAMINATION OF THE METHODS  AND INSTRUMENTS.     705

 mediately from the bladder.   The length of metallic sounds for an
 adult male is about twelve inches.  If they were shorter they might,
 in certain old men, not reach as far  as the bladder.   If they were
 longer, they would expose moreover to the risk of wounding the organs
 and perforating the  bladder.   Their diameter should vary from two
 to three lines.  They penetrate so much the better when every other
 proportion is attended to, as their volume is more considerable.  For
 children we  have them from a line to a line and  a half in diameter,
 and five to eight inches long.  If their wall has too. little thickness,
 they may bend or become deformed, or break even upon the slight-
 est effort.  A contrary arrangement would take up too much of their
 canal, and would interfere with the  flow of urine if the instrument
 did not possess a corresponding large calibre.   Their free extremity,
 which is ordinarily flaring in the manner of a pavilion, is furnished
 with a ring on each side,  in order that we may, if required, attach to
 it cords or threads.  At a few lines from the other extremity, which
 is blunt, are found  two lateral elliptical  openings, in place  of  the
 simple apertures which were formerly made there.  Those in which
 this extremity  is  replaced  by the head of a  stilette, which latter is
 pushed forward  in  order to  open the catheter, and drawn back to
 shut it, are scarcely any longer  used at the present day.  The same
 remark applies to those which are open and free at their vesical  ex-
 tremity.  The curvature which ought to  be  given to a catheter has
 given  rise to a great deal of  discussion.  If they are straight  it is an
 easy matter to push them forward like a cylinder by rotating them
 upon their axis,  and to overcome with these instruments obstacles
 which the others could not surmount.   But this advantage is more than
 counterbalanced  by the pressure which their point makes upon  the
 floor of the membranous and  prostatic portions of the urethra, and  by
 their tendency  to escape into false routes.  If they are curved they
 cause less pain, penetrate  better, and are in every respect preferable.
 The S shaped catheter of the ancients and of Erisistratus, (Macll-
 wain, Observ. de  Chir., fyc, p. 31,) and which was revived by J. L.
 Petit, and intended  to give  less fatigue to the canal when it was
 required to leave it there, has become of no value since science  has
 possessed the flexible  catheters.  If  the curvature should be very
 great and very much elongated, it serves no good purpose and inter-
 feres with the movements of  the hand.  The catheter which has the
 curvature only upon its end, as was  advised by Rameau, and since
 recommended  by M. Key and M. Stanley, (Ibid., p. 27,) penetrates
 with more facility than a straight catheter, but scarcely makes any
 less traction upon the infra-pubic portion of the urethra.   The most
 commodious  are  those which are  curved  only  in  their posterior
 fourth, in  such  manner as  to form an arc, the cord of which has  not
 more than three  to four inches  in length, and  the radius not more
 than one to two inches.  The  axis of their beak brought back in such
 manner as to cross at  a right angle the  imaginary prolongation  of
their body, is the  shape that I  have found the best, in cases especially
 where  the prostate is enlarged.  The  more it is turned backwards,
the more  difficult is it to enter into  the bladder or  to avoid our
 butting against the  lower wall  of  the canal, to count  from  the
perineal  aponeurosis.  The  silver wire  which they are provided
  vol.  in.                     89 
706
NEW ELEMENTS OF OPERATIVE SURGERY.
 with is scarcely ever of any utility, and does not even  possess the
 advantage of enabling  us to clear out the apertures  or to  cleanse
 their interior when foreign substances accumulate there.

                  § I.—Position of the Patient.

   In most cases it is a matter almost of indifference whether the
 patient be standing up or seated, or  lying  upon the  foot or edge of
 a bed or  table,  with his legs  hanging down or supported, or whe-
 ther he be merely placed in a horizontal position upon the bed.
 This last  position,  however, being the most convenient, is the  one
 which is generally  adopted.  The semiflexure of the limbs, and the
 separation of the thighs,  as recommended, give more ease to the
 operator,  and may contribute to stretch and straighten the urethra,
 but are not, however, in all cases a matter of any great importance.
 The same remark  applies to the position of the  head, chest  and
 belly, all  the muscles of which, it is said, ought to be carefully re-
 laxed
                 § II.—Position of the Surgeon.

   Unless  the surgeon is ambidexter, he places himself  on the left,
 and  cannot remain in front of or between the legs of the patient,
 unless this latter desires or has need  of being catheterized out of the
 bed.  With the left hand  turned in  semi-supination,  he seizes the
 penis by its sides between his ring and middle finger, then uncovers
 the glans, or at least the meatus, by drawing the prepuce back with
 the thumb and forefinger.   With his  right hand holding the catheter
 in the  manner of a writing pen, and with its concavity turned to-
 wards the abdomen, he  presents its extremity to the urethra  and in
 a perpendicular  direction, and passes  it in, in this manner, and with-
 out raising the  pavilion, down  to the  bulb.  By a vibratory move-
 ment made from right to left or from the belly towards  the space be-
 tween the thighs, a species of circular movement in  which the two
 extremities of the  sound  appear to  run  after each  other, he then
 lodges it in the membranous portion  under the  pubes, and makes it
 pass through the prostate and the entire curved portion  of the ure-
 thra in such manner that it may embrace, so to speak,  the  posterior
 side  of the symphysis, and  that its flaring  portion may be found in
 the axis of the lower strait.   The urine immediately presents itself,
 and the thumb allows it  to  flow or stops it, according as  mav be re-
 quired, by opening or shutting the orifice of the artificial  tube.

              § III.—Difficulties of the Operation.

  Catheterism is sometimes attended  with a great deal of difficulty.
It is  an operation which requires practice, accurate anatomical know-
 ledge, and a certain  number of precautions.   If the beak of the sound
 fell too much upon the lower wall of  the urethra, it would  not glide
 without difficulty, and might be arrested at the fossa navicularis then
in the bulbous cavity, afterwards by the prostatic depression, and de-
viate into  the bottom of either one or the other of these  dilatations
In forcing it to follow uninterruptedly the upper wall, such accidents 
          EXAMINATION OF  THE METHODS AND INSTRUMENTS.     707

 will not have to be apprehended, unless we raise it up too much and
 in" place of keeping its axis in relation with that of the canal, it should
 fall  upon a  more or less open angle  upon the  plane which it is to
 pass over ;  moreover, this bad direction, unless it  should be exces-
 sive, would  not be attended with any actual  inconvenience except
 on arriving  between the  roots of the corpora cavernosa at the ante-
 rior surface of the  symphysis.   The  important point, therefore,  is
 to make the catheter follow in the axis of the urethra from the meatus
 up to the bladder, by pressing it with some slight force upon its dorsal
 portion.  In this  respect there  can be  no fixed rule, because there
 are  no constant relations between this axis  and that of the body.   In
 sertain  patients it is necessary that  the  pavilion of the catheter
 should, so to speak, remain  parallel with  the walls of the belly, while
 we are passing through the spongy portions of  the organ ; while in
 other patients we are obliged to place it at the beginning, in the plane
 of the lower strait.  Force moreover is never required.   The in-
 strument should go forward as much under the  influence of its own
 weight as from the action of an external  power.  If it meets with
 resistance, we withdraw  it  a little,  in order to incline or direct it in
 another route.  In pulling over it the urethra from below upwards
 and  from behind forwards, as  a number of authors recommend, in
 conformity  to Le  Dran, we create obstacles instead  of destroying
 them.   This precaution cannot be of any utility except in the penic
 portion of the canal.  Farther on it flattens it, and has a tendency to
 efface it against the  border of the  infra-pubic  ligament, and must
 necessarily favor its laceration.   The  mode of entering the bladder
 with certainty, consists in allowing  the catheter to descend freelv to
 the origin of the membranous  portion, that is to say, to a line with
 the lower border of the symphysis, in such manner that it may not
 depress either the upper or lower wall of the urethra against the
 perineal side of the horizontal aponeurosis, then to make it vibrate
 suddenly though without effort, by depressing its  pavilion from before
 backwards,  to such  degree that it may become parallel with  the
 axis  of the thighs.   This movement conducts it forcibly into the  uri-
 nary bladder, provided  its extremity is  no longer  on this side  the
 pubes.   In the opposite case  it butts  against the  front part of the
 articulation.  The penis stands at an angle and the instrument springs
 back in place of advancing.   The difficulty most usually arises from
the operator  being fearful of depressing the outer portion too much,
and from scarcely  reflecting how much it is necessary to raise  up its
point, in order that we may  not be interrupted by the posterior bor-
der of the prostate.   However little resistance we may meet with
in approaching the symphysis, the left hand should proceed to  dis-
cover the cause of it, by raising  up the  scrotum and exploring  the
perineum, and by  endeavoring to identify the beak of the catheter
through the canal by  means of the  fore  and middle  finger, and by
following all its movements.  Should the instrument have advanced
a little farther than this, the  forefinger should be introduced into the
anus and intestine.   Serving  as  a  guide and explorative means as
above, it indicates  precisely in what direction the efforts of the other
hand are tending, or whether we are yet in  the membranous or in the
prostatic portion.   We discover by the thickness of the intervening 
708
NEW ELEMENTS OF OPERATIVE SURGERY.
 tissues, if there  is reason to presume that we have  made a false
 route, and the finger may if necessary assist in making the catheter
 take a direction  towards the bladder.   We must, nevertheless, not
 deceive ourselves upon the value of this manoeuvre, which is in no
 respect applicable to  rectilinear  catheterism.   By  raising up the
 prostate the finger increases the curvature of the urethra, has a ten-
 dency to apply it with greater force against the infra-pubic ligament,
 and naturally presents its soft or lower wall  against the beak of the
 catheter.   To derive all the advantage from it possible, it  is impor-
 tant, as soon as we have ascertained  the  state of the  parts and are
 desirous of exercising  the slightest degree of force, that we should
 withdraw the pulp of the finger a little to  the front, in  order  to fix it
 upon the  convexity of  the instrument  at a  little distance from its
 extremity.  In th.s manner the  portion of the canal  which remains
 to be traversed does not sustain  any pressure which can augment its
 curvature, while the combined action  of the two  hands is no longer
 attended with the slightest danger.

                              § IV.

   The signs which announce the entrance of the instrument into the
 bladder, are so evident  in most patients, that  they speak for them-
 selves, and  do  not require to  be  described.   But in certain cases
 many of them may be wanting,  and the diagnosis  is then so obscure
 as to give embarrassment to the surgeon.   If thick mucosities, san-
 guineous concretions, &c., become lodged in the  apertures of the
 catheter, the urine does not flow.   M. Berre, (Arch. Gin. de Med.,
 t. XVII., p.  105,) after having spoken  of  a patient affected with re-
 tention or suppression of urine,  during the space  of six months, and
 who should not have been surprised at the  case of M. Mathieu, (Ibid.,
 t. XVII., p. 279,) relates, that in applying the catheter  to another, he
 saw nothing escape by  the instrument, and that  this was  owing to
 the bladder  being filled with blood. Catheters which have a strong
 curvature, remain sometimes so closely applied  against the anterior
 wall of the bladder that they continue immovable, and shut up as high
 up as above the upper strait.   When  the  urinary bladder  is empty,
 retracted and very narrow, we penetrate  to  so little  depth, and the
 movements of the catheter of depression, elevation and rotation, and
 to the right and  left are  so limited, that we are induced to doubt
 in respect to the  place  that  the instrument  occupies.  A consider-
 able mass of blood accumulated in the  anterior half of the bladder,
 an instance of which M. Mathieu affirms that he has seen, would
 be well calculated to lead to deception, since we would be obliged
to pass through the whole  thickness  of  this  before  reaching the
 urine.  On the other hand, it has been noticed that the catheter, after
 having become entangled to a great depth in the tissue of  the recto-
 vesical septum, has been susceptible of movements almost  as exten-
 sive as if it had  been free  in the bladder.  We are still more liable
 to this error, when in consequence of a large ulceration in the floor
 of the urethra, a cavity  or accidental pouch of considerable size has
 been made in the tissues  of the  perineum  in front of the  rectum, a
 remarkable example of  which I saw in an adult  man, who died 'in 
        EXAMINATION  OF  THE METHODS AND INSTRUMENTS.      709

1825, at the Hospital of the School of Medicine, and as occurred  in
several other instances which I have since seen, and instances of which
have been also noticed, M. Roux informs me, by him.  This pouch in
fact may be taken for a diseased bladder, and so much the more so,
because the catheter, in penetrating into it, immediately gives egress
to a certain quantity of urine.

              § V.—The raising up of the Bladder.

   Without  speaking of hydatid (Bright, Gaz. Med., 1838,  p. 490?)
or other cysts, of collections of all kinds, tumors  and polypi which,
occupying the recto-vesical cul de sac  in man, the recto-vaginal cul
de sac  and  the vagina or  uterus in woman, sometimes push forward
the bladder  in such manner as to interfere with  the catheterism, and
to lead to  deception in respect to the point which the instrument is
passing; I will make a remark  here of another arrangement, which
is still too little understood.  It is believed, and it is generally true,
that the bladder, when distended by  urine, becomes dilated back-
wards and downwards in  such manner that it soon fills up the pel-
vis, and makes a strong prominence  in the rectum.  In such cases
there can be no  difficulty thereby produced for the employment of
catheterism.  But I have frequently observed an opposite arrange-
ment, that  is to say,  that the finger,  which upon entering into the
intestine, falls into a  sort of empty cavity, finds there neither tumor
nor prominences, and  that the  bladder  has mounted up entire into
the hypogastrium.  The same thing  must take place under such
circumstances as  happens  to the uterus during  pregnancy.   The
bladder assuming, in  consequence of  its repletion, the shape of a
bottle with  its  neck  downwards, and confined by the upper  strait
of the pelvis, gradually elevates itself, by becoming distended above
this cavity.   In  order to  reach  the bladder, it is indispensable
in such cases to  make use of  a catheter having its  beak  strongly
curved, and possessing itself a  deep, regular  curvature, and in the
form of the arc of a circle; and to  draw, by means of the fingea
fixed  in the anus, the sphincter towards us,  while  with  the other
hand  the catheter is  pushed forward with all suitable precaution.
The sensation that we have overcome a resisting point beyond the
pubes, the free action  which we suddenly find given to the  inner
extremity  of the  catheter,  and  the  facility  with which we  may im-
part to  it any kind of movement without causing any decided pain,
together with the route and direction which  it  must have passed
over, and finally,  the escape of urine, prove that we have entered
into the bladder;  but there  are cases  in which many of these signs
may be wanting,  and  others in  which  they  may be  counterfeited to
a greater or less extent.

                             § VI.

  After having tried in various ways, it is advisable, if the instrument
does not penetrate, to select another  whose  curvature is different,
and either greater or less, according to the indication which we may
believe to be presented, and also to find one of larger calibre, which, 
710
NEW ELEMENTS OF OPERATIVE  SURGERY.
 by straightening out and opening the canal in a more uniform manner,
 frequently passes, when the smallest kind would be arrested. At other
 times we  succeed better with a catheter which  is of decidedly less
 diameter; after which we proceed to make trial  of the gum-elastic
 tubes.  We change and vary the position of the  patient, and when it
 is no longer possible to attribute to the instrument or the operator the
 difficulties which present themselves, we  proceed to the examination
 of those which may er.ist in the canal  itself.  The tortuosities, con-
 genital or acquired, the  deviations in  consequence of diseases, the
 congestions  and humoral engorgement  of the mucous membrane or
 tissues which surround it, the varicose condition of the prostatic plexus,
 and extreme development  of the verumontanum or  of the vesical
 luette, a fibrous or other tumor on the posterior border or in the lobes
 of the prostate or on the trigonus, and finally, the spasmodic contrac-
 tions of the perineum or of the urethra, are in this respect the principal
 obstacles that we encounter.   We avoid  or overcome some by well
 directed movements.   The others require  to be met by various means.
 A powerful bleeding by the arm, leeches  between the scrotum  and
 anus,  general baths, continued for a long time if the patient is strong
 and suffers much, anodyne  potions, and pomades of belladonna and
 hyoscyamus applied over the  track of the urethra and in the anus,
 when  the irritability is very great and the spasmodic movements de-
 cided, constitute the series of remedies to  be made use of in  such
 cases.   An adroit and skillful surgeon will scarcely ever fail to suc-
 ceed by using each of these judiciously, and at the proper time, and
in succession.   If spasm  of the  urethra,  properly so called, actually
exists, and we  may wait for a few hours without any danger, we
must meet it, as I have said, by taking the precaution  to  divert the
mind of the  patient as powerfully as  possible, as is recommended by
 M. Macllwain,  (Observat. de Chir., &c, p. 31 ;)  but in urgent cases
we should do every thing in  our power  to overcome  it, and it is a
matter of  doubt in my mind,  if with a  person of a practised hand it
could  in  reality constitute  an  insurmountable  obstacle:   It would
be a subterfuge far too convenient also  for unskillful persons, if we
were to admit, as they do, that spasmodic contractions exist merely
because it is impossible for them to  reach into  the bladder.  As a
 contraction of this kind must  necessarily be of  short duration,  and
does not completely obliterate the urethra, it must be that art can tri-
umph  over  it by exercising a little patience, and by making use of
small, or even large instruments.

                  &  VIl.—Flexible Catheters.

   With flexible catheters we traverse the urethra in the same man
ner as with the  preceding.  It is nevertheless true, that as  a general
 rule they  penetrate with less facility than silver catheters.  If we
 have to  introduce them into a tortuous canal, we  remove the stilette
 from them, in order that they may inflect upon all the deviations that
 are to be overcome.   On the contrary, we insert  into  them a metal-
 lic stem, which  should be as strong and as regular as possible.  This
 stem,  which is curved like the ordinary catheters, becomes  their con-
 ductor, and ought to occupy them as  far as to their inner extremity 
          EXAMINATION  OF THE METHODS AND  INSTRUMENTS.     7ll

 and to go  beyond their  outer extremity, where it is usually termi-
 nated in a  ring.   It is important to guard with care  that it does not
 escape through the apertures of the catheter, for it would expose to
 the risk of wounding the urethra.  Though it may be easy when it
 passes under the pubes to increase its curvature by means of the fin-
 ger slipped into the rectum, it is  more prudent however  to give it
 before commencing the operation  the direction that may be required.
 AH that is required to withdraw it is to bring it back towards the
 abdomen with the right hand, while the left hand secures the  cathe-
 ter below and pushes it toward the bladder.  If this manoeuvre  is
 sometimes  more painful than  the operation itself, it is from  its having
 been badly executed.  It does not take place if we make the stilette
 on coming  out describe the same arc of a circle that it did on enter-
 ing.   Some persons after  the manner of Hey, have succeeded very
 well after they have  reached the pubis, in acting no longer on the
 stilette, but in holding it fixed with one hand while with the other we
 oush exclusively on the catheter, the blunt and flexible beak of which
 passes with more facility  through  the remainder of the urethra when
 it is thus by itself alone, than if it was conducted by  the stilette.
 Others improving upon an idea of Physick, make use of such flexible
 catheters as have their beak tapered out in the shape of a long conical
 point, which  is pliant and solid,  and  extends  beyond  the stilette.
 Hey, with the view of irritating the bladder less, proposed to give a
 permanent curvature to these catheters, which modification various
 French surgeons  have adopted, and which in my opinion has no
 other inconvenience than  that of being too great.  As catheters of
 gum-elastic or flexible ivory are employed only in those cases where
 it is desirable to leave them remaining in the bladder, they are enti-
 tled in this respect to  all the attention  of the practitioner.  In the
 first place, their composition ought to be such that  no inflection can *
 break  or  chafe them, or destroy the polish or smoothness of their
 surface.   Unless this  were the case, they would soon become rugose
 in the urethra, and too speedily acquire an incrustation from the uri-
 nary salts;  while any body may understand what may be the con-
 sequence  if a fragment of one  of them should fall into  the bladder, as
 has  but  too frequently  happened.  The best test that we can put
 them to, is that of bending them or twisting them suddenly on  their
 axis.   If they resist and do not change in their aspect, we may em-
 ploy them with confidence; in the contrary case, they are  to be re-
 jected.   The  projection of red wax, which  is found  on their outer
 extremity, is for no other  purpose than  to form a groove there for
 the cords  which we use in attaching them; it would prevent them
 also from  passing  completely into the urethra, and of escaping to-
 wards the bladder should  the hand let go its hold upon them.  We
cannot at  first understand  how it could be possible for a  catheter of
 10 or 12 inches long, left to itself, to escape-entire into the urinary
bladder; but there exist indisputable evidences  of this fact, and M.
Roux was compelled to perform  cystotomy for an  accident of this
description. 
712
NEW ELEMENTS OF OPERATIVE 3URGERY.
                              § VIII.                           #

     The catheter is fixed in the bladder in an  infinite number  of
  ways, all of which have  been described in the first volume  of this
  work.  An important precaution is not to have it inserted too deep.
  Though flexible, it may inflame, ulcerate, and perforate the bladder,
  instances of which are known, and a certain number of examples of
  which  have been  stated  by MM. H. Berard, Corby, and Marjolin.
  If, on the other hand, its apertures  should not go beyond the prostate,
  the urine could not pass into them, and the instrument would be of no
  use.  Finally, it is advisable not to leave more than an inch  or two
  of it in extent in the interior of the organ, and when the penis is re-
  laxed, to attach it near the glans. instead of placing the containing
  means on its pavilion or at its extremity. Unless we desire to allow the
  urine to run out drop by drop, we shut up the catheter thus adjusted
  by means of a small peg of wood  or a kind of fasset, which the pa-
  tient  removes when he feels a desire to urinate, and replaces imme-
  diately afterwards.  As it does not absolutely prevent the patient
  from walking, we may make it more supportable and guard it  better,
  by taking the precaution to keep it  gently turned back with the penis
  by means of a turn of bandage over the mons veneris.  Prudence also
  requires that it should be withdrawn  every two, three, or four days,
 ' in order to clean it, and that it should  be  changed as  often as it ex-
  hibits the slightest alteration;  which happens every 8, 10, 12, or  15
  days.  In keeping it in for a longer time, we incur the risk of having
  it become encrusted with saline or  calculous matters, and finally of
  its lacerating the urethra when we wish to withdraw it.

,            § IX.—The Master Turn, (tour de maitre.)

   In former times  lithotomists and the great surgeons had a peculiar
  manner of performing catheterism.  In order to introduce the cath-
  eter, they turned its concavity downwards, and only  brought it back
  again towards  the abdomen by a half turn of a circle°at the in-
  stant when its beak arrived under the  pubic ligament.   The rest of
  the operation did  not differ from the one above  described, and the
  improvement consisted in making  the circular  pass imperceptibly
  into the vibratory movement, which alone could justify the expres-
  sion tour de maitre.  It was for a long time thought that this method
  had no other object in view than that of concealing from the eyes of
  the assistants the true nature of catheterism ; but it would appear to
  comprehend something more.   The extremity of the catheter con-
 ducted in this manner executes in the curved portion of the canal  a
 movement of rotation which unquestionably facilitates its passage
 under the symphysis, and we combine  by this means the advantages
 of straight  catheters with those which are possessed by the curved
 instruments.  As however it is a delicate manipulation, which would
 not be unattended with danger in the hands of every  one it has een
 erally been proscribed or reserved for some special cases'   It is ren
 dered necessary, for example, where  there is an extreme projection
 of the belly, or when in lithotomy we place ourselves in front of the
 patient in order to  introduce the catheter.   Even  there, however  it 
         EXAMINATION OF THE METHODS AND INSTRUMENTS.      713

is not indispensable, for nothing prevents our turning the pavilion of
the catheter to one side  during the time of the operation, if the size
of the belly or the forced position of the surgeon  do not allow him
to direct the -instrument as in ordinary cases.

                  §  X.—Catheterism in  Women.

   Female catheters have but five or six inches in length and scarcely
any curvature.   Their introduction in general is a matter of extreme
facility.  The canal that they have to  pass through is so short and
regular,  and so easy to find and to follow, that it scarcely  resembles
in anything that which exists in man.  The patient when laid on her
back is more  conveniently situated than when she is standing up or
seated on  the edge of her bed.  The  surgeon, on  his part,  being
placed to the right  rather than to the left, causes her  thighs to be
widened apart and her legs to be gently flexed ; placing his left hand
in pronation upon the mons veneris, he opens  the labia minora,  by
means of his thumb and middle finger ;  raises up the clitoris and ves-
tibulum  with the forefinger, the nail of which is to remain turned to-
wards the meatus urinarius ; takes the catheter, which has been pre-
viously oiled, and holds it in the manner of a pen in his right hand;
passes it underneath the  corresponding  ham, if the breech and vulva
appear to be too deep ; presents its beak with the concavity upwards-
to the  orifice of the urethra and depresses it a little in order to pass it
underneath the symphysis ; then immediately raises it up, and with
one movement enters into the bladder.
   A.  Having pointed out the mode of  keeping the instrument in its
place, under the article of Vesico-vaginal Fistula, and in Vol. I., of
this work, I will not here return to this subject.   This operation is so
alarming to the modesty of certain females, that it would be a fortu-
nate thing if we  could perform it without exposing their persons to
view.  This thing is generally practicable and  even easy of execu-
tion.   If after the left hand has been placed as above described, the
beak of the catheter is placed  upon the nail of the forefinger, all that
will afterwards be necessary will be to make it glide gently upon the
vestibulum by following  the median line from above downwards, by
which  means it falls almost inevitably into the meatus.  We should
succeed with  more certainty still, by directing the catheter from be-
low upwards, supporting its extremity upon the pulp  of the right
middle finger, while  the ring finger of the same hand serves in some
respects  as a  sentinel or exploring instrument.  In fact this  finger
recognizes the fourchette, then the entrance, and  afterwafds the an-
terior columna of the  vagina, the termination of which latter,  and
which is  more or less dilated in the form of a tubercle, is found im-
mediately below the urethral orifice.  Having arrived  at this  point,
the ring  finger stops.  The other fingers cause  the sound to glide
upon its pulp and  make use of it as a conductor.   The meatus cannot
be at a greater distance than a line or two.  We feel around a little,
and almost always enter into the canal without  any difficulty.
  B. In  women who have had many  children, in old age, during
pregnancy and after delivery, the finding of the  urethra is sometimes
attended with considerable difficulty.  Having  receded into the pel
  vol.  in.                     90 
714
NEW ELEMENTS OF OPERATIVE  SURGERY.
 vis behind the pubes, it becomes very oblique, or is even raised up
 completely against the  symphysis.   In such cases we seek for its
 meatus quite deep under the pubic ligament, and if it does not show
 itself at first, we endeavor to bring  it  into view by-drawing, by
 means of the forefinger, upon the vestibulum and base of the clitoris
 above, at the same time that the middle finger and  thumb draw the
 nympha3 with considerable force to the outside.  The catheter having
 been introduced, it becomes necessary to depress its pavilion quickly.
 We are even sometimes obliged to  make use of one of greater cur-
 vature, or to have recourse to a male catheter.  In conclusion, even
 when the parts are deformed, as during the first days  succeeding
 delivery, for example, if the surgeon  calls  to mind that  the meatus
 urinarius  is always situated at the anterior  border of the vagina, at
 the point of union of the circumference of the vulvar opening of this
 canal with the base of the vestibulum, that  is to say, of the little tri-
 angular cavity which forms the limit to the inner side of the nymphae
 and  lower side of  the clitoris, he will  find that catheterism is  in no
 respect an operation attended with  any serious difficulty in persons
 of the female sex.  The thesis of M. Larcher, (No. 339, Paris, 1834,)
 and what I have elsewhere said on  this subject, (Art  des Accouch.,
 2d edit., Paris, 1835, t. II.,) will serve  as a supplement  to this article.

                             §XI.

  In the early period of life, catheterism is only difficult in conse-
 quence of the intractability of  the patients.   The catheters  ought to
 be of less size, that is from one to two lines in diameter, and of less
length, that is, from five to seven  or eight inches long,  but prepared
and conducted and fastened in the same manner as in adult age ; ex-
cept that  it  is well to have the  curvature  a little more elongated,
because of the sym*physis which descends lower down, the  bladdei
which  is more raised  up, and  the prostate  which  is of less size in
voung boys than in men.
                        CHAPTER  II.

               CONTRACTION OF THE URETHRA.

  Catheterism,  forced injections, dilatation, cauterization, excentric
incision or scarifications, together with incision from without inwards
have all been recommended and employed as remedies in organic co-
arctations of the urethra.

               Article I.—Forced Catheterism.

  By forced catheterism is meant at the present  day two kinds of
operations, which are quite different from each other.  In one we
make use of a blunt-pointed instrument, but one that is conical and 
FORCED CATHETERISM.
715
sufficiently sharp to penetrate with considerable force into the blad-
der in passing along the track' of the urethra ; in the other we employ
a cylindrical large sized instrument, with  the sole view of  dilating
the natural contracted canal.  One is used for retention of urine and
the other for contractions of the  urethra.

        § I.—Forced, Ordinary or Evacuative Catheterism.

  When there is a complete state of ischuria, and when  the obstacle
which causes it cannot  be overcome  by any manoeuvre, either by
means of  the metallic or gum-elastic sound,  the straight  or the
carved, the hollow or the  solid, nor  by means  of the various kinds
of bougies, and  that  the symptoms are urgent, the surgeon has no
other choice  left than puncture of the bladder or forced catheterism.
This  operation had already been recommended at the time of Deaz.
To perform it they had  recourse to a sound which terminated  in a
trochar point.   At present, those who venture upon  this operation
make use of a strong  conical sound, which is properly curved.   The
idea of this operation is ascribed to Desault and  Boyer; but  Cof-
finiere, who warmly contested  their pretensions,  avers  that it be-
longs to  him and  that he had made it known in 1783.   In France,
M.  Roux is almost the only person who, since the time of Boyer, has
undertaken to advocate it; with the exception of Physick, who, ac-
cording to  Dorsey, had followed this practice since the year  1795, it
has had  nothing abroad  but opponents.  It has been supposed  that
by endeavoring  to remove  obstacles in this  manner, the sound would
lacerate the canal  and make a false route much oftener than it would
perforate through  the coarctation, and with  those,who know the
dangers of urinous infiltrations,  the idea of such lacerations seemed
exceedingly alarming.  In  this respect I consider that  the  greater
number of practitioners  have not been in  error.  Notwithstanding
his dexterity  and skill, M. Roux  has in more than  one instance had
an opportunity of  verifying the dangers of  his method.   I have my-
self had an occasion of opening  the dead body and of dissecting the
urethra of a man whom he had  treated  in this  manner, and who
died of urinous abscesses caused by a false route.  Nevertheless, it
appears certain  that the dangers bf this process have been exagge-
rated. The  instrument  if properly  conducted, does not always, in
passing through the resisting point, deviate from the natural track.
Again, when it actually forces itself through it in place of reopening
it, the instrument,  if it actually escapes from  the  urethra, does so in
most  instances only to re-enter it again at a few lines beyond.   Fi-
nally, upon the supposition that  it does not reach the bladder  until
after having been working  its way for a long time  through the body
of the prostate,  the accident is still far from being always fatal.  A
sound left remaining in, may transform the false route into a new pas-
sage, without the system being scarcely affected by it, an instance of
which I saw in 1830 in one of the hospitals of Paris. Nor is it a rare
circumstance to  find the  urine resume its course, after the lapse of a
few hours or some days,  through its natural canal, and I cannot say,
in fact, if forced catheterism with a conical sound ought  not to have
the preference over puncture of the bladder, with all such surgeons 
716
NEW ELEMENTS OF OPERATIVE SURGERY.
as are sufficiently sure of their  hand and in  their anatomical know-
ledge, not  to  have any appprehension of making a false  passage
while traversing the perineum.
  A. Operative process.—The  patient and  surgeon are  placed in
the same way as for ordinarv catheterism.   The  heavier and more
solid the sound is, the better "it will penetrate.   The ordinary sound
exposes to  the risk of laceration more than any other, and would
not re-enter into the urethra with sufficient facility, unless the form
of cone which it has, tapered gradually back as far as the pavilion.
If this  cone was limited only to the vesical  extremity, it could  not
progress with sufficient facility.  If it once got out of the  canal, it
would advance too rapidly in  the midst of the tissues.   In generah
force is  not required until we leave  the bulb and line of the sym-
physis.  The right hand is then to approach  the glans penis, and the
instrument  to be seized rather  by its body  than at its extremity, in
order that  it may vacillate  less, and  that it may be held with more
facility, and with all the firmness desirable ; it is  then  pushed  for-
ward exactly in the known direction of the  urethra, without allow-
ing it to make the slightest deviation, or  to progress except  in pro-
portion as the fingers or one of the fingers of the  left hand,  applied
over the perineum or into the anus, shall watch over its movements,
and  can appreciate its progress, and convey to us the assurance
that its beak has but slightly deviated from the  centre of the mem-
branous and prostatic portions of the passage which is to be trav-
ersed.
  B. False routes.—The short sound, in lacerating the urethra in its
bulbous portion, runs the risk of tearing also the whole extent of the
perineum and recto-vesical  septum, or may go  even so far as to per-
forate into  the intestine before it again  finds  the urinary canal, or
it may  not enter into  the bladder  at all.  The false  route is then
so much the more  dangerous, inasmuch  as it  does not even afford
egress  to the urine.   Should the laceration have taken place above,
and the point of the sound have got between the posterior surface of
the symphysis and the front part of  the bladder, the mischief would
be still greater, for the  infiltration which  would  take place in  the
pelvic  cellular tissue,  would  almost unavoidably result in death.
False routes through the prostate are infinitely less dangerous :  1st,
because the tissue of this gland makes greater  resistance to  the con-
tact of urine and generally prevents its infiltration; 2nd, because the
instrument, though  it has slightly deviated from the channel which
is to be liberated,  almost  always  re-enters into  it before  having
caused any particular injury, and before having passed to any great
extent outside of it.  When it has  been ascertained  that we have
made a false route,  we must, should it not be complete, withdraw the
sound towards us, and do every thing in our power to find the  ure-
thra again, and to re-enter  into the natural passage ; or if this route
has made a communication with the bladder, we must leave the instru-
ment in, until it is in our power to replace it by a gum-elastic cathe-
ter, which  should be left to remain  there for the space of several
days.   When infiltration has  taken place,  and the accidents  and
tumefaction, and inflammation  have commenced, whether the blad-
der be empty or not, or whether it be possible  or not to  place a ca- 
FORCED CATHETERISM.
717
theter in the urethra, we must  no longer  hesitate, but  make a free
incision upon  the  presumed track of the  laceration, and  endeavor
to cut down upon  the urethra.  It is  the only way to  limit the ex-
tension of the mischief, and to prevent the mortification of the tis-
sues.

             § II.—Forced and dilating Catheterism.

  A new mode of treating contractions of the urethra by catheterism
has been introduced into practice  since the year 1830.   M. Mayor
of Lausanne,  author  of this  method, (Cathet. Simple et Force, &c,
1835,) laying it down as a principle that the sound in  order  to  be
enabled to penetrate, ought to be so much the more voluminous as the
contraction is  more considerable, created at first much  astonishment
among practitioners ;  but having invoked to the support of his axiom
some arguments that were specious, together with a certain number
of facts, it soon found partisans even  in the hospitals.  Having, on
my part, noticed that  frequent trials of this process were being made
at Paris, I deemed it proper to  examine the question under its  dif-
ferent aspects.  I  soon perceived, as was  established also  by  M. A.
Vidal, (Journ. Hebdom., 1835, t. IV., p. 353.) and as was maintained
by M. Gaillardet, (These, No. 342, Paris, 1836,) a  short time  after-
wards, that this new method  taken  in its  literal Acceptation was a
dangerous  one,  that  the  successful results obtained from it were
more apparent than real, and that they were ascribable to a confu-
sion of terms.  With  M. Mayor's sound in fact, we cannot succeed
but in two kinds of cases.  1st. When there  is no contraction, and
when we use the process I pointed out in 1832.   2nd. When the ob-
stacle is purely valvular, because an incomplete  diaphragm, as it
may be  more easily straightened and  spread out in a passage regu-
larly distended,  ought to be ruptured with more facility and with
more accuracy by a large and heavy sound than by a  slender  and
slight instrument.   Otherwise,  and in real coarctations, the Mayor
sounds cannot penetrate but by tearing up  and lacerating the tissues,
and by exposing the patient to serious dangers.
  Had not  the proof of what I here advance been  given by MM.
Vidal and  Gaillardet, I  could  produce it in the cases themselves,
presented by M. Mayor and his disciples.   What do we see, in fact,
in what has been published on this subject ?   The instruments of M.
Mayor are  of pewter,  and either hollow or solid, curved according to
the direction I have given for  them, and  divided  into  six varieties
or numbers, counting  from two lines to four and a half  lines.    In
the first of the  cases related by this surgeon  they began without
difficulty with No. 1 ; which, according as it seems to  me, does not
authorize us to assert that the urethra was  actually contracted.  The
second patient was an  Englishman,  whom a cauterizer  could not
sound, but who by means of a large catheter succeeded in sounding
himself.   In the third patient  they employed in succession three
numbers of the  elastic sounds,  and  afterwards the numbers  of the
pewter sounds.  The  fourth had undergone puncture of the bladder
for ischuria ; M. Mayor sounds him ; the patient  dies, and it is as-
certained that his urethra was  perfectly free !  No. 1  entered with 
718           NEW  ELEMENTS OF  OPERATIVE SURGERY.

facility in the fifth, though there was retention of urine.  The seventh
and  eighth  were  easily sounded  from the first  by Nos. 2 and 3.
Finally, the author completely failed in the sixth  patient, who was
affected with an actual  organic coarctation, (see Mayor, Oper. cit.,
pp. 36,37,39,40, 41,42, 49,50.)  For myself, I am convinced that in
these different cases the affection was an ischuria  from deviation of
the urethra or disease of the prostate, and  not from any coarctation
of the canal whatever.   I would say the same of the patients  of M.
Chaumet, who employs  large silver sounds in place of those of pew-
ter.   In the first case he succeeded with a sound of three lines, though
another surgeon who had  employed a fine sound had failed; but  he
confesses  that the obstacle was at the prostate.  The same thing ex-
isted  in the  second case, and the man was 67  years of age,  (Gaz.
Med., 1834, p. 814.) In the third case he was stopped at the distance
of six and a half inches, and  consequently it was at the  prostatic
region ; and his fourth patient from being attacked with  ischuria at
84 years  of age, (Ibid., 1835, p.  769,) certainly owed this affection-
also to the condition of his prostate.   As to the practice of M. De-
vergie, (Ibid.,  1835, p.  782,) who  moreover adduces in support of it
the essays of MM. Desruelles, Henri,  Barthelemy,  &c, and who
actually had to do with  contractions  of the  urethra, it  has not in
fact any positive relation with forced  catheterism.   In every instance
in fact, in which the contraction was  at the distance of two, four or
five inches, they began with cauterization or bougies, or Nos. 1, 3, 4
and 5 of the ordinary sounds, before proceeding  to the  use of .the
Mayor instruments.  Now who does  not perceive that in proceeding
in this manner  they followed the principles laid down by me in this
work a long time since, and not those of the surgeon of Lausanne 1
Need I add that the seven patients  mentioned by M. Boinet  (Gaz.
Mid., 1835, p.  721) were all, like those of M. Vidal, attacked with
grave accidents, in consequence of the forced catheterism ?  This
mode of practice therefore at the present day is definitively adjudged.
The essays which I have just spoken of only prove, as I had said in
1832 : 1st, that for  retentions of urine caused by a tumor or disease
of the prostate, or by a  flattening  or deviation of the urethra, sounds
that are large and  heavy, and regularly curved into an arc of  a cir-
cle in their vesical half, are better than the  ordinary sounds  or bou-
gies;  2d,  that it is practicable and often advantageous to  proceed in
a few days from the first to the last numbers of the common bougies
or sounds, while treating contractions  of the  urethra ; and 3d, that the
instruments of M. Mayor, with these exceptions, and examined under
this point of view, will  notwithstanding  render essential service to
the patient.

                Article  II.—Forced  Injections.

  A means to  be made  trial of when there is retention of urine  be-
fore proceeding to paracentesis of the bladder, and one which  is  not
attended with the same dangers as forced evacuative catheterism. is
that of distending the urethra by means of a liquid thrown up from
before backwards.  Trye, who was the first to  make this  sugges-
tion, namely, in the year 1784,  states that he  derived  the  greatest 
INCISIONS AND SCARIFICATIONS.
719
 benefit from it, and Soemmering mentions that where the finest bou-
 gies cannot be made to overcome the contraction, he injects oil into
 the canal, then immediately shuts up its orifice, and afterwards makes
 pressure  from  before backwards, in order to push along the liquid.
 The  method of Brunninghausen is somewhat different.   At the mo-
 ment  when  the  patient has a desire to urinate, he  forcibly makes
 pressure  upon the urethra behind the glans penis, compels the fluid to
 retrograde, and  in  this manner expects to  destroy the  contrac-
 tion.   In 1^22. M. Despiney of Bourg proposed a liquid which was
 purely emollient, and which was to be pushed up with a syringe.
 M. Citadini, (Rev. Med., 1826, t. II., p. 493,) who has published a
 memoir on this  subject,  introduces  a catheter down to the point
 of resistance, holds the urethra firmly applied upon it,  and  makes
 use of it as a syphon to inject into the canal tepid water or any other
 suitable liquid with all the force that may be required.  M. Amussat,
 who considered himself the inventor of forced injections, proceeds
 nearly in the same manner as M. Citadini.  He recommends that we
 should apply a compress around the penis, in order that no void may
 be left between the catheter and the walls of the canal, that we should
 afterwards attach to the pavilion of this catheter a caoutchouc bottle
 filled with water, and that we should push up the injection by making
 pressure upon the elastic bag by means of a tourniquet; but it is rea-
 dily perceived  that after the  principle  has been  laid down, it is a
 matter of little  importance whether the liquid be projected by means
 of a syringe, a gum-elastic bag, or by the finger or any other mode.
 This  method, though rational  and of undoubted  efficacy in certain
 cases, is  far however  from  deserving  those  eulogies which some
 persons have bestowed  upon it.  If the urine, which is a sort of natu-
 ral injection thrown  from  behind forwards,  cannot  overcome  the
 coarctation, nor make it disappear nor  prevent it from manifefting
 itself,  how can we hope that any liquid whatever, merely from the
 fact that it is propelled in an opposite direction, can triumph over all
 obstacles  ?  It is therefore probable  that the successful  results that
 are imputed to  it, might have been full as well obtained by means of
 catheters  or bougies introduced in a  proper  manner, and that in  the
 majority of the cases injections might have been dispensed with, if
 the ordinary processes had been employed in a more judicious man-
 ner.   Nevertheless, as they are of easy employment and unaccom-
 panied with any inconvenience, I see no reason why they should not
 be made trial of, and  even without waiting until all the other means
 have failed.

  Article III.—Incisions  and Scarifications on  the contracted
                              part.

  The practice which consists in applying a cutting instrument to the
interior of the urethra to destroy its contractions, though it is already
quite ancient, and one which Muzell (Rougemont, Bibl. Chir., p. 375,)
still eulogized the benefits of, in the last century, has never had many
partisans.   Besides  the almost  utter impossibility of reaching only
the contracted point, the danger of incising sound rather than  dis-
eased  parts, and the alarm which it  must necessarily give the pa- 
720
NEW ELEMENTS OF OPERATIVE SURGERY.
tient, this method also has the inconvenience of presenting but a very
slight chance  of a radical cure, and of rendering the coarctation
greater after the cicatrization of the small wounds than it was before
the operation.   Of two things one must take place : either  after the
incision  has been  made, we would leave the canal to itself, and  the
wound would in this case, from  its  cicatrizing by first intention, dis-
appear after the expiration of 4 days; or we would keep  it  dilated
by means of catheters or bougies, and  in  this case we should have
secondary cicatrization.   Now it is  demonstrated at the present day
that these  secondary  cicatrices,  when  left free, invariably  recon-
tract, and  reconstitute  the  coarctation at that  point upon  which
the instrument had  found it, if in fact  they do not render it more
hard and more difficult to be overcome or destroyed.   The facts  ad-
duced against this  course of  reasoning prove  nothing, since  in  ad-
mitting them to be true, the dilatation employed as an auxiliary to the
incision  is  sufficient to explain the successful results that have been
related.   But in addition to this we have the fact, that in most in-
stances the incision has  not even reached down to the contraction,
and  if afterwards  this latter  appeared  to  have been  removed, this
was effected only  by  means  of the dilating instruments, which  the
uretrotomists never fail  to make use of immediately after  the ope-
ration.  Finally, experience daily shows that the return of the dis-
ease, after  the incision,  takes place in the same way as after simple
dilatation.   I have  had,  besides an infinite number of other  instan-
ces, two of a remarkable character under my observation, although
the two patients, who had each been incised  twice, at an interval
of a year, had been treated by one of the most zealous and  pre-
sumptuous  scarificators of Paris.   This, therefore, is a method which
can  be applicable only to bridles, and to valvular or semilunar con-
tractions, or to  fibrous  nodosities,  and  one which, with  these  ex-
ceptions, would  scarcely be  made  trial of, unless by inconsiderate
persons, destitute of accurate knowledge either  in anatomy  or sur-
gery, or by specialists.

                    §  I.—Operative Process.

  Inasmuch as it  may  happen  that in  spite of  the  preceding re-
marks, some' persons may, nevertheless, continue to cry up  incisions,
and as they may in the last extremity become necessary, in  certain
cases of well  ascertained  contractions  that are too  hard and  too
thick to  yield  to  the distending  action of a  bougie,  I proceed to
point out the manner in which  the operation should  be performed.
Dorner, to  whom  Siebold  and Soemmering  ascribe  the  honor of
this process, recommends that  we should make use  of  a sort  of
lancet, which is to be  introduced through a  catheter.    Physick
speaks very highly of an instrument of the  same kind:  it  was  a
stem terminated in a small  fleam (flammette),  enclosed  in a can-
ula  of  sufficient  length,  and which was pushed out by  makin^
pressure on its  free extremity.   We find in Dorsey's work two  ure^
trotomes of this description, one which  was without any  curvature
and which was designed for coarctations of the straight portion of
the canal, and the  other, which was somewhat more strongly curved 
INCISIONS AND SCARIFICATIONS.
721
 near its point  than a female catheter, and  which was destined to
 attack the contractions of the bulb and membranous portion.  Ran-
 dolph alleges  that M. Gibson has obtained  from these instruments
 successful results,  that no  other  method  could have possibly  pro-
 cured.   But who  does not  perceive that the cutting fleam (onglet)
 of Physick or Dorner, would, in most cases, whatever  address  we
 might use,  become involved  in the tissue of the canal, than in the
 centre of the obstacle itself, and that in a great number of instan-
 ces  it would leave the contraction  itself wholly  untouched.   M.
 Despinay, (Bull, de Fer.,  t.  X., p.  278,) who  allows  of incision only
 in cases of narrow contractions in  form of a bridle, and at the  an-
 terior portion of the urethra  or neighborhood of the fossa navicu-
 laris, for example, recommends that we should make it with a straight,
 very narrow and blunt-pointed bistoury.  The bistoury of Bienaise,
 or the  small concealed uretrotome  of M. Civiale; would evidently
 fulfill this indication better.  No one, moreover,  can question the ad-
 vantages of this operative method  over that which was followed  by
 Physick.  As the  incision would  be made by a lateral movement,
 and  from behind forwards, it could  not expose  to the risk of false
 routes, like that which is effected from before  backwards, and beyond
 the conducting instrument.
   M. Ashmead, adopting the suggestion of the practitioner of Bourg,
 has had  constructed a concealed bistoury like that of F. Come, the
 sheath of which is  prolonged  into a blunt or  probe point in order to
 go beyond the obstacle, while the blade has a cutting edge only to
 the extent of six or eight lines near its extremity, in order that when
 opened it may incise only  the contracted part, and which instrument
 its author supposes could be applied  to every portion of the  urethra.
 M. Guillon, (Trav.  de la Soc.  de Med. Prat., 1831, '32,  p. 33,) who
 appears to have been well satisfied with scarifications, has contrived
 for this  purpose sarcotomes and  uretrotomes, which  are still more
 ingenious than those of M. Ashmead.   M. Tanchou has also invented
 some.  M.  Raybard,  (Proc nouv. pour  guirir par  Vincision  les
 retrecissements  du canal de Vuretre, Lyon, 1833, in 8vo.,) also in
 resorting to the incision of contractions of the urethra, makes use  of
 a bridle cutter or uretrotome  with one or with  two cutting edges, and
 which are  terminated by a probe-pointed stem  contained  in  the
 interior of a catheter.  Others, as  Dzondi at first and M. Amussat
 afterwards, have contrived a stilette with four, six or eight cutting
 crests parallel to its  axis, which project to the distance of half a line
 or a  line at most from the  circumference of its vesical extremity,
 which latter should  be a little dilated to the  extent of six or eight
 lines.  The intermediate grooves are filled in with ointment.  This
 stilette is introduced into a straight  canula, through which latter it is
 conducted down in front of the obstacle.   Having reached that point
 it is pushed upon, protrudes from its  sheath and enters into the con-
 traction.  The oiutment melts or recedes before  the resisting point.
 The small crests thus  denuded, slit  the contracted circle on different
 portions of it in the manner of a scarificator.  The instrument is then
 withdrawn.  A  flexible catheter or  bougie  is then immediately sub-
stituted in its  place and  left to  remain there for the space of  at least
twenty-four hours, after which  it is to be reintroduced from  time  to
 vol. ih.                     91 
722
NEW ELEMENTS OF OPERATIVE SURGERY.
 time until the cure is completed.  In order that an instrument of this
 kind may penetrate it is necessary that the coarctation should exist
 to a very slight extent, for its point, which has to pass first, and which
 is without a cutting edge, has a diameter of nearly two lines.  As the
 introduction of a sufficientlv large bougie could not  then be attended
 with any difficultv. it would be in vain here to try to discover a rea-
 son to justify uretrotomv.   The same objection is to be made to the
 instrument of M. Ashmead, as well as to the process  of M.  Despinay ;
 with this difference however, that this last mentioned uretrotome, from
 being capable  of assuming the form  of a bougie or a probe, passes
 through the obstacle  in the  manner of a catheter, and does not divide
 it until afterwards as a secondary operation.  As it  unites  the advan-
 tages of the uretrotome with those of conducting catheters  or dilating
 bougies, it may be directed  only upon one point or may divide several
 of them  successively at  various distances, according to the pleasure
 of the operator.  This is the  instrument therefore, or one of those
 which will be found  in the atlas of this work, which would be most
 applicable should  it  be absolutely necessary to have recourse to the
 method of incision.
                              §  II.

  What I have said on the subject of scarifications is  to  be under-
stood  also of Rugination.  Dionis,  (Cours  d'Operat., edit, of La
Faye, pp. 272, 273,) who  does not  believe  in carnosities  in the
urethra, and  who considers that contractions in this canal are the
results of clap, while he censures the cutting catheter of Pare had
suggested this process (rugination) in the 17th century.  This how-
ever did  not  prevent A. Pare, (CEuvres Complet, tyc, p.  536.) who
recommends  that we should rasp down the carnosities in the canal
with a kind  of file,  from  being imitated by M. Desruelles,  (Nouv.
inst. appeli porte-rdpe, pour le traitment des retrecissements de Vure-
tre, eye,  in 8vo.,  Paris, 1836,) who  treats coarctation by  means of
an actual cylindrical rasp  introduced in the manner of the  caustic
holder of Ducamp.  The  experience which I  have had with this
instrument has satisfied me that it  possesses no utility, and that it
will not be retained in practice.

  Article IV.—External  Incisions.—Button-hole  Incision,
                          (boutonniere.)

  Coarctations of the urethra are so frequent, and the accidents which
 they occasion are so  serious, that the ingenuity of surgeons has been
 constantly occupied  in .seeking a remedy  for them, and  the most
 painful and the most dangerous methods been proposed to effect their
 removal.
                              § I.

  Planque (Bibl. de Med.,  t. III., p. 253, in 4to,) has published the
 instance of a surgeon who  had  the boldness to lay  open the urethra
 from one end of it to the other, in order to cauterize and change its
 interior, and who  afterwards united  the wound  upon a catheter by
 means of several points of twisted suture, and thus it is said cured his 
EXTERNAL INCISIONS.
723
 patient, which practice was generally adopted at Livourne  at  the
 time of Solingen.   In place of incising it throughout its whole length,
 a great  number of practitioners adopted the method of dividing the
 urethra only at its  contracted portion.   J. L. Petit, who was a parti-
 san of this method, did not leave  the wound to cicatrize on his S
 shaped catheter, except after an operation of this kind ; while Lassus,
 according to M. Dolivera, substituted, in 1786, a gum-elastic catheter
 for that of Petit.   M.  Levanier of  Cherbourg, (Arch. Gen. de Med.,
 t. IX., p.  413.) encountering an obliteration which was almost com-
 plete, ventured to revive the process of Petit or Lassus, and his bold
 attempt was crowned  with  success.  Had not several surgeons  en-
 deavored to bring this practice into repute again, it could  have been
 dismissed in two words; but it has  been too frequently made trial of
 for several years past to allow  me to pass it over in silence.

                    §  II.—Operative  Process.

   M. Eckstrom in  Germany, M. Arnott, (Bull, de Fer., t. II., p.  81,)
 in  England, and M. Jameson, (Ibid*., t. XVII.. p. 253.) in America,
 who have derived decided advantages  from it, make their incision
 into the urethra in the following manner.  A  catheter, or grooved
 sound, is  introduced down to the obstacle, and held there by an  as-
 sistant.  The surgeon  raises up the scrotum, stretches the parts with
 his left hand, and  with a bistoury in  his right hand, makes a large
 button-hole like incision on the  perineal wall of the passage opposite
 to the  conducting instrument, which latter is to be withdrawn a short
 distance ;  he then endeavors to find the continuation of the urethra
 at the bottom of the wound, while the patient at the same time  makes
 an effort to urinate; he now tries to glide into it a probe or grooved
 sound, which he makes use of as a  director for the purpose of pro-
 longing the incision  backwards to the distance of some lines beyond the
 contraction, and terminates the  operation by leaving a catheter to re-
 main permanently in the passage and  bladder, and upon  which it is
 said the  incision soon  cicatrizes.   M.  Lefebvre, of Joinville, (com-
 municated by the  author, 9th May, 1839,) in  adopting this method,
 obtained a perfect  cure in  a man  whose urethra had been diseased
 for a long time.
                              §  III.

  When  there  is  a complete obliteration, or the discovery of the
aperture of the canal is attended with too much difficulty, M. Groni-
ger recommends that we should incise  at hazard as far down nearly
as to the prostate, that  we should then penetrate  through this gland
into the bladder by a narrow bistoury or  trochar, in such  manner as
to create an artificial canal, which is to be kept open by introducing
into it through the meatus urinarius, as in the preceding case, a ca-
theter which is to be left there,  and upon  which the whole wound is
to close up.  If, as  Shaw lays  it down, (Bull, de Fer., t.  II., p. 80,)
the contractions were always to be found anterior to the membranous
portion of the urethra, and that there  constantly exists a dilatation
behind them, the operation thus projected might be performed with
 considerable facility so far as relates to its first  stage; but this is  far 
724
NEW ELEMENTS OF OPERATIVE SURGERY.
from being generally the case, especialIv in those contractions which
succeed  to ruptures.   M. Cox, (The  Lancet,  1828, vol. I., p.  278.)
who recommends the same method, cites in support of it a fact which
he considers among the most conclusive, but which  in reality shows
rather the extent 'to which  the  temerity  and  fatuity of some prac-
titioners  will  lead  them.  The fact is, that the urethra is scarcely
ever completely closed up by its organic contractions.  In admitting
that the simple  button-hole slit may  be sometimes  indispensable, and
that forced catheterism, when we "find it impossible to pass a bougie,
should not be preferred to it, we may at least affirm  that this incision
ought, with an  experienced  person, to be sufficient  to lay bare  the
continuity of the canal.   Puncture of the bladder would certainly be
less dangerous,  more prompt, and far less painful than the process of
MM. Groniger and Cox.  I doubt moreover if any French practitioner
at the present day  will find himself under the necessity of adopting a
course like th's, or that the  simple  button-hole incision itself will be
very often had recourse to by them.   I would  add that this canal of
a new formation would not be kept open, and that it would shut up
in spite of all our efforts.

                   Article V.—Dilatation.

                       § I.—The Process.

  The treatment of coarctations of the urethra  by dilatation, and
which is  the most ancient known, was for a long  time  the  only one
in use.  The leaden bougies  formerly  employed, and again extolled
by  M. Herzberg, (Bull,  de  Fer..  t. XIV., p. 205,) together with
those  which Schmidt had constructed  with a mixture of lead and of
tin,  being, though flexible, too hard and too heavy for the urethra to
support them without inconvenience,—the wax bougies, and  those
of gum-elastic, are the only ones which have continued  to be used in
practice.  The  first, which were formerly made of different substan-
ces, were especially extolled by Lamna, in 1551, and  by Daran in
1745.  Since the utility of their medicated properties  has  been  de-
nied, and that their mechanical properties only  have  been  considered
of any value, the resolvent, astringent, desiccative, and other mate-
rials of which they were composed have  been replaced  by yellow,
white, or  red wax, which is  reduced  to  a flexible state.   The only
qualities  exacted of them at the present day, are that of being
supple, smooth, insusceptible of melting inthe organs, capable of adapt-
ing themselves to all the inflexions of the canal,  and free from any ten-
dency to break.  The leaden wire which some persons place in their
centre, in order to  increase their solidity, is without any  utilitv.   A
fine and delicate catgut is better, if we  absolutely decide  upon  not
using those which are  made with  emplastic tissue.  M. Guillon,
(Trav. de la Soc Aled. Prat., 1831-2, p. 32,) with a view of having
such as were sufficiently strong, though  at the same time very de\t
cate, and with  a cylindrical, olive-shaped, conical,  and  dilated (a
ventre) extremity, &c,  had some fabricated  of  whalebone.. The
fact is, I  have seen him succeed with  bougies  of  this kind in* cases
where every other description had failed.   Dilating bougies and  va- 
DILATATION.
725
rious kinds of dilators for  the  urethra, moreover, have been  con-
trived by M. Montain, (Therap. Mid.-Chir., p. 19.)
   A. The gum-elastic bougies, which are  smoother,  more flexible,
and still less irritating than  wax bougies, have on the other hand  the
inconvenience of fatiguing the urethra more by their elasticity itself,
and their tendency to straighten out, however small a volume they
may have; from whence it happens, that even in their character as
foreign bodies, they cannot  be substituted in every respect for em-
plastic  bougies, as Soemmering and most moderns allege.  The bou-
gies and  sounds  of  ivory,  rendered flexible, as made  by  MM.
D'Arcet and Charriere, from their possessing the pliancy and solidity
of the gum instruments, and from their susceptibility of dilating, by
imbibing  humidity in the passage, would have  been generally intro-
duced into practice, in such manner as to remedy the inconveniences
of bougies hitherto employed, were it not for their tendency to  be-
come dissolved.  Both these kinds are of various forms.  They  are
either cylindrical, dilated, or conical, &c.  The conical bougies, in-
creasing in volume in proportion as they penetrate, possess the  ad-
vantage of dilating the constriction rapidly, and of not easily bend-
ing  in the passage; but they have the inconvenience of a tendency
to escape from it, of  filling  it up  too entirely, and consequently of
fatiguing it in the direction of their base; and moreover, if they  are
very much elongated, of protruding to a distance into the bladder be-
fore they have acted in a  proper manner  on the  contracted portion
of the urethra.  It  would be necessary that  their point, which should
at first be sufficiently delicate, should not  be farther than  12  to 18
lines from the body of the cone, and that they should afterwards be
nearly cylindrical as far as to their base ; it being well understood that
the bougies below 8 or 6 do not need this modification, which would
weaken them without giving them any real  advantage.
  B. The bellied (a ventre)  bougies deserve to be more frequently
used.  The fusiform dilatation of their fifth vesical portion, does not.
when  it is  sufficiently elongated, prevent our making  them conical
in this direction, while from  the manifestly less considerable volume
of their stem, they  concentrate  almost their entire action  upon  the
contraction itself, cause but little irritation in the urethra, and are kept
up without  difficulty.  M. Desruelles, (Journ. de Prog, des Sc. Med,
t. XVIII., p. 143,) adopting  this suggestion, has  gone  so far as to
propose that we should substitute for bougies a metallic canula ©f an
inch or two in length, which should be left at the  centre of the con-
tracted point, after  having introduced it there by means of another
instrument, and in such manner  to be enabled to retain it by means
of a thread fastened outside.  But the bellied bougie answers a bet-
ter  purpose. As it enables  us to increase the dilatation to such ex-
tent  as we desire, it causes less pain than the conical bougies.   The
action of bougies or sounds on the contraction has not always  been
regarded in the same point of view; at the present time we  allow
nothing more to these instruments, than the property of ulcerating
and  that  of dilating.  This  is evidently an error.  The excentric
compression which  they make, from its tendency to promote  inter-
stitial absorption, may dissipate the inflammation which in so  many
cases sustains the callosities  in the urethra, at the same  time that it 
 726          NEW ELEMENTS OF OPERATIVE SURGERY.

 may efface and distend them.  The radical cure which they obtain
 more frequently than one would be induced to believe if we credited
 the relations of certain authors, can scarcely be explained in fact, in
 any other way than  by this remarkable effect.   This, moreover,
 might lead us to believe that it was probably an error to reject med-
 icated bougies in so absolute a manner, and that their topical action
 has only perhaps  been denounced because it was  not understood.
 Those who have adopted the method by ulceration, support them-
 selves upon this ground, that a coarctation which  has been  merely
 dilated must  necessarily return as soon  as we dispense with the use
 of  the dilating body, but  that by effecting  a loss of substance, we
 must on  the contrary obtain  a permanent enlargement of the canal.
 E.  Home in still maintaining a doctrine of this  kind,  has committed
 a double error.  On the  one hand, a return of  the disease does not
 inevitably  follow  the dilatation;   while  on the  other, the  ulcer-
 ation involves a loss of substance, the  cicatrization of which  would
 be  much more  certain  to  reproduce the  contraction.  Moreover,
 there is nothing to  show that we could in reality produce this con-
 traction at pleasure.   A bougie introduced  forcibly into the infundi-
 bulum of a coarctation, or kept pressed into the middle of the con-
 tracted circle, irritates and more promptly dilates, but does not ul-
 cerate the part, or  at most does nothing more than excoriate it.
  D.  The  medicated  action  of bougies being laid aside, though  it
 may one day be revived, no other  importat point therefore remains
 to be considered than their distending power in its various degrees
 and under its different aspects.  This  effect is  certain and  almost
 unavoidable ;  but  it possesses the inconvenience of not being  main-
 tained with sufficient  permanency, and that also of being limited  in
 the greater number of patients who submit to it, to the palliation of
 the disease instead  of curing it  without a return.   Nevertheless,
 those coarctations  which are not produced either by a bridle,  or
 valve, or projecting cicatrix, nor by vegetations,  of whatever nature
 they may be,  but  which  arise from a pure and simple, or inflam-
 matory, or other induration  of the mucous membrane and subjacent
 organic tissue, are however in a considerable number of cases perma-
 nently removed under the action of a dilatation properly performed.
 Moreover all  that  would be required  to prevent a  return,  would
 be to replace the  bougie every month, and afterwards  every two,
 three or four  months, and to keep it  in for the space of several hours,
 which precaution will be so much the  less irksome to patients  from
 its being very easy for them to perform the operation themselves.

                   §  II.—Operative Process.

  When  the  urethra is very much contracted, the passing of a bou-
gie  is not always an easy matter.   If it is too small it bends  before
the  slightest obstacle, while if it is a little larger,  it is not  possible for
it to enter.   The catgut bougies, which are stiffer and have more
force under a smaller volume, present some advantages under  such
circumstances.  Delpech recommends that we should flatten and bite
their point a little,  in order to transform them into a kind of supple
 and flexible pencil; after passing through the obstacle he withdraws 
DILATATION.
727
them at the expiration of two hours;  he then introduces one a little
larger and renews this after the same interval, and replaces this again
the same  evening when he considers it practicable, by a bougie  or
sound of  gum-elastic.   The distension they undergo  gives  great
value to a dilating instrument under such circumstances ; but as they
become twisted,  softened and knotty, we  should incur the risk  of
breaking  them or of abrading the urethra, should we delay chang-
ing them  every two or three hours.
   A. Hollow Bouqies.—In many cases also a small catheter or hol-
low bougie is  more  convenient  to commence with.  The stilette,
which it is furnished with, ought to be well  curved as far as to  its
point and possess all the strength possible.  The whole is then to  be
introduced into  the bladder according to the rules of catheterism.
Moreover it is prudent to have at the same time in our case, ca-
theters, bougies  and catgut-sounds, in order to  be enabled,  when
necessary, to make  use of these instruments in succession.  There
cannot be any  fixed  position  for  the  patient.   We sometimes
leave  him standing up, or make him sit down,  or place him in a
horizontal position.   The penis, which is generally  held slightly
raised up, requires in other  cases to be a little depressed  or drawn
forward.   The patient, guided by the sensation he experiences and
the resistance  he feels as soon as the point  of the bougie deviates
from the axis of  the canal, will sometimes succeed with the instru-
ment at a  time when the most skillful surgeon would have failed.
The failure of a first attempt is no argument in respect to the second.
A thousand  particularities, which  practice alone will enable us  to
distinguish, may  oppose us at first and a moment afterwards enable
us to succeed.   In fine, we proceed  nearly in the  same manner as
for catheterism.  The penis is held in the left hand and the bougie
pushed in with the right.   The smallest kind easily become caught
at the bottom of  the lacunae of Morgagni, or in the slightest  dupli-
cature of  the canal.   Should there be ever so little  resistance, we
must, after having withdrawn it a  few lines, turn it in the manner  of
an  axis between our fingers,  while continuing to push it forward
near the difficulty.  A cul de  sac, or  fold, or false direction, or ru-
gosity, or  the projection formed by the coarctation itself, may arrest
its  march.  It  is under  such  circumstances, particularly, that we
must make it progress with caution, bring it back  towards us,  vary
its inclination, turn it between the fingers, and favor its passage  by
means of  the forefinger resting upon  the perineum.  We know that
it  has entered into the contraction when, without any inclination  to
advance farther, it has no tendency to recoil, and  is found as it were
compressed at its point.   We may be  certain of the contrary, when-
ever it springs back as soon as we cease to make pressure apon it,
and that it offers  no resistance  to the hand when we are disposed to
withdraw  it.  A  practised person will  not be deceived, and will ap-
preciate better than can  be  described, the difference which  exists
between a bougie which is fastened in the coarctation and one which
is only stopped  by it.  In  the first case, as it can  only be  prevented
from  passing on by  its excess of volume, we have nothing  more
to do than to replace it by a smaller one, or to fix it at the point in
which it has entered.  In the second  case, we repeat our attempts 
728
NEW ELEMENTS OF OPERATIVE  SURGERY.
in every possible way, using a larger or a smaller bougie, or one of
another form or of another description.  Finally, we may fix  it in
the point of the urethra which it has entered, provided its extremity
has not bent up.   It not unfrequently happens  that when arranged
in this  manner, it  will of itself overcome the obstacle, and that at
the expiration of a half an hour we shall find  that we  can make it
advance to a considerable  distance with the  greatest degree of fa-
cility.   This  course, which was adopted  by  Dupuytren, enabled
nim to  succeed in  numerous instances, and  in some cases where
success was  unhoped-for.   Should the passage  appear to be  too
much irritated or in too painful a state, or if it should bleed copiously
or become  spasmodically contracted, every manoeuvre is to be sus-
oended, to  return to them at a subsequent period when these acci-
dents shall have subsided.  Those  emplastic bougies, in which we
nave taken the precaution to give them a curve  near their extremity,
cannot, it is true, be any longer rolled between  the fingers, but they
accommodate  themselves better to  the direction of the parts, and
m some certain cases surmount a difficulty  which  has resisted all
me other kinds.  Dipping  the penis in cold  water, warming the in-
strument before introducing it, covering it with cerate after having
r»iled it, or  besmearing it with pomade of belladonna or opium, will
sometimes  render  that  easy which seemed to  be  impossible.   A
fbng,  blunt-pointed probe, with a ring  outside,  and  pushed in while
turning it around, has full as well succeeded with me in many dif-
ficult cases, as it did with MM. Bell and Vanvelsnaer, who proposed
it in 1814  and 1821.   Its  button extremity is  an excellent means
of overcoming  the  most irregular coarctations,  and  enables  us in
this manner, as M. Segalas has remarked,  to  measure the extent
of the  contraction.
  B. I will now suppose that the bougie is finally adjusted  in  its
situation.   In order to fasten it we confine ourselves, if  it  is an em-
plastic and dilated  one, to bending that extremity which is near the
glans penis into the form of a hook or ring.   When it is cylindrical
or merely conical, it is necessary, moreover, to  invest  it with a cun-
dum or a small  sac of fine linen, which at the same time envelopes the
penis. The gum-elastic bougies require, in this respect, the same atten-
tion  as  catheters  that  are to be left to remain in, and which  have
been mentioned farther back.   The  time proper to leave in the first
ones varies according to an infinite number of circumstances, that is,
according as the canal is more or less irritable or sensitive, or sound,
.moreover, or diseased, or whether the  person experiences a gveater
or less degree of pain from the bougie, or  the coarctation has existed
a greater or less length of time, or is more or less  decidedly marked,
and according to the effect also which we wish to produce.   It rarely
happens however that it is to be left in for less than half an hour, or than
one or two hours, or more than  twelve or fifteen hours, and it may
remain as long in fact in general, as  the patient  can  support it  with-
out experiencing too much suffering.   If the patient experiences an
urgent desire  to urinate, and the fluid cannot  make  its escape be-
tween the walls of  the canal and the foreign body,  the conical bou-
gies have in  addition this advantage, that by withdrawing them a
little the urine passes with facility, and that we  may readily replace 
DILATATION.
729
 them afterwards at the same depth as before.  The flexible cathe-
 ters, whether cylindrical or conical, and the  hollow bougies, are val-
 uable in this respect, that it is unnecessary to change them  in  order
 to empty the  bladder,  and  because certain patients  cannot retain
 their urine over an hour, or even not as long.
  ^ C. Nor can there be any fixed rule in  respect to the interval of
 time between each application.   We are sometimes obliged to wait
 two or three days, while in other cases the system becomes so quick-
 ly habituated to it, and is so little  disturbed by it, that we may re-
 peat the application on the following day.  In renewing them,  we
 take one which is of a little larger  size, as often as  the last made  use
 of has begun to pass freely into the urethra, but as the conical bou-
 gies become larger and  larger in size in proportion  as they penetrate,
 they do not so  absolutely exact this  reapplication.  The more  we
 advance in the  treatment, the more frequently do we make the appli-
 cations, and the longer do we protract their duration.  It may be laid
 down as a principle, that every contraction which  can  be traversed
 by a bougie, however small the latter may be, may be cured by di-
 latation.   This  treatment, which is so much the longer in proportion
 as the stricture  is so much the  more indurated and more resistant,
 and according  as  the patient is more excitable or more difficult to
 control, is sometimes not terminated until after the  expiration of two
 or three  months; but I have acquired the conviction  based upon a
 sufficiently extensive number of observations, that we  may in the
 majority of patients succeed in the space of from 20 to 30 days in
 restoring to the  canal in  this manner its natural dimensions, especially
 by means of the conical  bougies.
   D. I  have even frequently obtained these dilatations in the space
 of 6, 8,  12, or 15 days, in patients in whom the contraction was  of
 several  years' standing, and in some other patients  who had been al-
 ready treated either by bougies or cauterization, but  in  whom the
 cure  did  not   remain  permanent.  Since  I have mentioned  this
 manner of dilating the urethra,  it has found  distinguished partisans.
 M. Lallemand,  (Pirondi,  Gaz. Med., 1835, p. 764,) who employs it
 under the title  of sudden dilatation, and who administers  copaiba
 with the intention  of temporarily dilating the urethra before the  in-
 troduction of the  first bougie, has derived excellent results from it.
 M. Lasserre,  (Bull, de  VAcad. Roy.  de  Aled., Paris,  1839, t. III.,
 p. 603,) who with  the intention of suddenly enlarging a contract-
 ed urethra, introduces successively  into the bladder 12 numbers of
 the sound,  does no more  than follow mv  practice.   Finally, the
 dilatation which M. A. T. Chretien (Bull, de Ther., t. XVI., p. 288)
 eulogizes under the title of sudden dilatation, is also scarcely any other
 than an  exaggeration of the process which I have just pointed out.
  E. Moreover,  I know nothing  of the dangers with which dilatation
of the urethra is generally reproached, nor of the pains that  certain
authors  ascribe to it.  When systematically performed, I  have rare-
ly seen it produce  severe accidents.  The mucous, or blenorrhagic
exudation, that it sometimes occasions, almost always disappears  of
itself after having  lasted a few days.  The fever, preceded  with
trembling, and followed by sweats as in intermittent fevers, which it
causes in certain cases, has nothing  alarming  about  it.   The nervous
   vol.  in.                      92 
730
NEW ELEMENTS OF OPERATIVE  SURGERY.
 symptoms, and engorgement of the cord or testicles, are exceptional
 accidents, which are not more frequently caused by the employment
 of bougies than by the most simple form of catheterism.   A patient,
 however, upon whom I had used this process at La Pitie, was seized
 with symptoms which  it is proper to notice.   A conical bougie had
 been passed after several trials.  One morning this man, wishing to
 introduce it himself, by its head, (chef) could not succeed, and made
 the canal bleed.  The  exacerbation of fever, which had accompanied
 the first  attempts, was renewed, and continued three days, and did
 not cease on the fourth until it was replaced by a violent tibio-tarsal
 arthritis,  which was  followed  by an extensive abscess, and after-
 wards by anchylosis.   It is true that this leg had  been fractured
 above  the malleoli six  weeks before.  Was  this  a  coincidence, or
 was it an effect of the same kind as those which are quite frequently
 caused by blenorrhagia ?   The objections which  may in reality be
 made against this mode of treatment, are that of exposing to a return
 of the  disease, that of requiring that the dilatation should be carried
 beyond the  normal  dimensions of the urethra, and that the bougies
 cannot be abruptly laid aside, but must continue to be made use of
 from time to time during the space of at least several months.
  F. A small cylindrical or fusiform pouch, supported by a probe and
 contained in a flexible canula, and thus  suddenly introduced into the
 contraction and then filled by insufflation, forms an air dilator, which,
 according to Ducamp  and M.  Arnott, ought  to  be substituted for
 dilated bougies,  and presents the important  advantage of forcibly
 distending the coarctation without having the slightest action on the
 rest of the canal.   At the  present day we know that this is not the
 case; but that the small  bladder necessarily adapts itself  to the
 urethra, and that it presses full as much on this side and beyond as
 upon  the contracted  circle  itself.   M.  Costallat has shown me
 another apparatus of this kind, which is composed chiefly of a  long
tube made of fine linen, which  is introduced  into the bottom of the
urethra by means of a  flexible tube.   This tube, which terminates in
a cul de sac  at its vesical  extremity and  is open  and has a ring at
the other extremity, is destined  to receive small portions of lint or
cotton, which, by means of a forked stem, are pushed and  crowded
into the coarctation  in  such manner as to obtain as rapid and  pro-
gressive a dilatation as  may be desired.  However ingenious these
inventions may be, I doubt if they will be adopted in practice.   As
bougies almost always enable  us  to  attain the  same object,  they
deserve, by their simplicity,  the preference that they will probably al-
most always have.                                           J

               §  III.—Contraction of the Meatus.

  In man the coarctations of the urethra scarcely ever take place in
the prostatic  region    As this  canal, unless it  is  stretched,  has
scarcely more than four to five inches in front of this gland, we  mav
from that conclude that any operation performed at more  than six
inches of its depth can  no longer have relation to a contraction of
the urethra.   At the bulb and in the corpus spongiosum, and up to
 as far  as  an inch from the prostate,  the coarctations of  the  ure- 
CAUTERIZATION.
731
 thra  should be  treated in  the same way as those  of the membra-
 nous portion; but at the meatus they require  some special precau-
 tions. Their incision isthen so easy a matter that we ought generally
 to give it  the preference, or make  it  the  point of departure for the
 rest of the treatment.   The ordinary crayon of nitrate of silver re-
 places, under  these circumstances, the other instruments.   To effect
 the dilatation  we have no need  of  a bougie.  A  sort of a plug of
 adhesive plaster rolled up on its spread side,  and an inch long, and
 which the  patient withdraws and reintroduces  himself every time he
 has occasion to  urinate, is used in place of a bougie.

                             § IV.

   In women, the contraction of the urethra, three  instances of which
 I have seen, and a case of which, where it was formed by a sort of
 valve, was noticed by M. Mannec, (Bibl. Aled.. 1829, t. II., p. 443,)
 and another instance of which was also seen by M. Larcher, is to be
 treated in the  same way as those of the region which I have just been
 speaking of in man.

                  Article  VI.—Cauterization

  The surgeons of the 15th, 16th, and 17th  centuries, considering
 that  contractions of the  urethra  depended upon vegetations  and
 fungosities, were in the habit of treating them by caustics.  Verdi-
 gris, vitriol, savin, and alum, mixed together into emplastic compo-
 sitions, which were  shaped  into bougies,  were  employed for  this
 purpose.   A. Ferri, A. Pare, F. de  Hilden, and Riviere speak of it as
 a method  in very common  use and frequently  dangerous.   It  is
 known that Loyseau ventured to have recourse to it upon Henry IV.,
 and that Limonier, Wiseman, and Roncalli also extolled it.  But in
 the last century  it was scarcely any longer as much  spoken of.   But
 for the improvements and ameliorations which  it has received from
 the hands of Hunter, E. Home, Arnott, Ducamp and several others,
 this method, which has ultimately succeeded in being adopted, might
 have been, without  any inconvenience,  allowed  to  remain in the
 oblivion into which it had fallen.

                              § I.

  The nitrate of silver, substituted in the place of sublimate  and
other caustics  which  were first employed, has,  it would seem, dimin-
ished its  dangers, and reconciled  to  it a number of persons.  By
demonstrating afterwards the possibility of touching only the diseased
part, confidence has finally been imparted to the public and cauteriza-
tion of the urethra been made, so to  speak, a common method.  It.  is
not however to be supposed that  Pucamp was  the original author of
these improvements.   The impression bougies (bougies a empreintes)
were in  use  at  the  16th  century.   F.  Germain and L. Muzell,
 (Rougemont, Bibl. Chir., p. 372) also  advise that we  should ascer-
tain  the seat and form of the contraction with the extremity of an
emplastic bougie, and then withdraw it and remove a  layer from its 
732
NEW ELEMENTS OF OPERATIVE  SURGERY.
point, in order to substitute in the place of this some caustic substance,
which is to be reintroduced upon the bougie thus armed into the con-
tracted canal, in  the same way as was done at the  time of Dionis,
(Cours d'Operat., edit, of La Faye, p. 273.)   The process of Home,
which consists in attaching a small quantity of nitrate of silver to
the point of a bougie, to be introduced down to the contracted  part,
scarcely differs from that of Germain or Muzell.   We see also that
Pare anticipated Hunter by proposing a canula to protect the urethra,
while we introduced the bougie charged  with caustic, and left  it to
act.   Limonnier also, as M. Dezeimeris remarks, knew how to search
out for the difficulty, and  to take the imprint of it by means of wax
before proceeding to cauterize.   F.  Roncalli, in  the year 1720, more-
over made use of the same caustic that Hunter did, or the same process
as Pare, and the practice of Wiseman was so much in use at the time
his countryman was trying it  that Allies, in  1755,  complained  of
the fatal  accidents which it frequently produced at Paris.  Notwith-
standing the remarks and  modifications of M. Wathely, the method
of Home, introduced into France  by M. A. Petit in  1818, (Revue
Med., 1837, t. III., p. 360 ; Bull, de la Fac de Med., 7th annee, p. 106,)
had been so severely censured  by MM. Rawley and  Carlisle among
others, that even in  England it continued  to be the subject of various
prejudices,  and that the memoir of M.  Arnott,  based upon the same
principles as  that of Ducamp,  produced scarcely any sensation at
London in  1819,  no more than  that of M. Macllwain, published in
1830,  will bring into repute the use of potash  extolled by M.  Wa-
thely in similar cases.

                              §11.

  Cauterization from before backwards, with or without a conduct-
ing canula, has almost entirely disappeared from  practice since the
time that Arnott and Ducamp made  known  their method.   If, after
the example of M. Leroy, any persons should still incline to make use
of it, the armed bougie of Home and of M.  A.  Petit, from its  being
flexible, ought  to have the preference for those contractions which are
situated near or beyond the bulb. If it is pushed rapidly in, it will not
without difficulty  allow the caustic, which is  upon its point, to  touch
the walls of the urethra before it reaches the contracted infundibu-
lum ; we then  push  it in a little farther; the nitrate  now melts, and
we then draw  out the instrument at the expiration of about a minute.
When the obstacle is at less depth, the canula of Roncalli or of Hunter
may be  employed  without  any inconvenience.  M. Chas  Bell and
Shaw considered  that the  beak of a metallic catheter, which should
be straight or curved, according to circumstances, and pierced  in the
centre it  the constriction is central, and on the  side  in the contrary
case, would fulfill with more certainty the same  indication, by civinc
us all the liberty desirable  to introduce  and protrude  from one of
these  holes, a piece of caustic, either  by means  of a bougie  or a
long forked probe, or any other appropriate instrument 
CAUTERIZATION.
733
                              §  III.

   Lateral cauterization  exacts  more  precautions, and is performed
by various processes, which all belong  to the same method.
   A. The apparatus of Ducamp consists of: 1st, an exploring sound,
designed  for  ascertaining the depth  at which  the  constriction  is
placed ; 2d, an impression bougie, having a certain quantity of soft
wax  at its  extremity; 3d, a conducting catheter, having  a platina
socket at  one end, and enclosed in a silver tube at the other ; 4th, a
caustic-holder, consisting of a small platina cylinder, hollowed out by
a slit on one of its sides,  and having near its root  a transverse pin, to
prevent it from going beyond the beak of the conductor, and also
having a flexible stem, which  it is screwed upon, and which is con-
tinuous at the other  extremity with a metallic probe armed with a
ring.  The small socket  of platina is filled with fragments of nitrate
of silver  before screwing it upon the flexible  stem.   Always taking
care to grasp  this  between the branches of a strong pair of forceps,
we then place it above a taper or candle with  a steady flame, in or-
der to melt  the caustic slowly, and that it may not bubble up, as fre-
quently happens when it is too quickly heated, or when the socket
has not been well cleansed and dried.   Nothing further remains than
to regularize the whole,  by grating down the  projections or asperi-
ties  which  may  have formed,  by means of  pumice-stone, or the
cutting edge of any instrument whatever.  We may then commence
the operation,  after having accurately determined with the exploring
instrument, the place where the obstacle is situated.  The impression
bougie  is the  first which  is  introduced.  It  is  kept  for a moment
against the contraction, when the soft wax fills it up and  gets lodged
in  its passage.   It  is then withdrawn, and  the size of its elongated
point furnishes the measure of the diameter which is to be traversed,
at  the same time that the impression which is  transmitted should in-
dicate to us whether the  coarctation  is  central or circular, or in the
contrary case on what part  of the urethra it exists.   The conductor
is then introduced  to the  same depth, where it is held with the left
hand, after which we seize with the right hand the ring of the caustic-
holder, which is to be pushed in  in such manner as to protrude the
platina  cylinder, charged with nitrate, while  turning its socket to-
wards the diseased wall,  so as to  make  it enter  in fact into the con-
tracted circle.   The wings of  its pin are arrested within the socket
of its conductor.   We leave  it a minute, or  only half a minute in
contact with the tissues.  After having withdrawn it into the interior
of the catheter, we remove the whole apparatus, and the operation
is terminated.  In  acting in this  manner we cannot, should  there be
several contractions existing at the same time, attack the most remote,
until after having destroyed in succession all the others.  The matters
which the organ secretes,from being liable to get  into  the conductor,
quite frequently dissolve  the nitrate before  it can  become lodged in
the contracted passage.
  B.  M. Lallemand is one of the first who endeavored to remove
this  inconvenience.   His caustic-holder, which is terminated  by a
button, and the whole of which consists  of one piece, together with
the stem which gives it motion, is straight or curved, according as it 
734          NEW ELEMENTS OF  OPERATIVE SURGERY.
is intended to penetrate to a greater or less distance, and enclosed in
a platina catheter or sheath, having the same  shape and a greater
diameter than  is necessary, in order that it may be adjusted with ac-
curacy upon the socket or swollen portion  of the  stilette.   A run-
ning ring, armed with a pressure screw, embraces the conducting
canula.   The  stilette has at its other extremity a lenticular button or
nail, which is not adjusted until after having inserted the instrument
from behind forwards into its sheath or canula.  By drawing it to-
wards us, the slight dilatation of its head completely closes up the ves-
ical extremity  of the catheter, and transforms it into a blunt point.
It is introduced in this manner, shut  up, into the urethra, and  as an
explorator as  far as  the bladder, in order to  satisfy ourselves that
there is no longer any obstacle remaining.   If there are several of
them, we may stop upon»the last full  as well  as upon the first, and
cauterize  them  from  behind forwards, or from before  backwards,
either in succession or all at the same sitting.  When it is inserted,
we bring down and fasten the running ring on a line with the mea-
tus urinarius, in  order not to lose sight of the  distance at which the
contraction is  situated.  By afterwards drawing the sheath towards
us, the socket of the stilette is disengaged and  strikes naked upon the
diseased tissue.  For the purpose of  closing it  up in order to with-
draw it, or for pushing it in and bringing it  into contact with other
contractions, it is a matter almost of  indifference, whether we make
the sheath move on the stilette, or  the stilette  in the interior of the
sheath, by pushing one in or drawing back the other.   In this appa-
ratus several stilettes are necessary if the instrument is  curved, be-
cause from being wholly metallic, they cannot turn  on  their  axis in
the  interior of  the  canula, and that their socket has necessarily
a fixed point.  Thus, it is necessary to have such as have the socket
on the concave border, some with the socket below, and  others that
have it placed on  the side.   We must also have  them of different
sizes, together  with sheaths whose calibre  must proportionally vary.
  C. M. Segalas, with the  view of preserving the advantages of the
instrument of  the professor of Montpellier, without losing those of
the apparatus of Ducamp, makes use of a  stilette, which  in its fourth
inner portion is formed of small links of a chain, like the lithotritor
of M. Pravaz, and by which he is enabled to execute all the move-
ments of rotation required, and to turn his  socket towards the  dif-
ferent points of  the diseased circle in succession.  Moreover, in or-
der to make it penetrate  down to the first contraction, he incloses it
armed with its sheath in the conducting catheter of Ducamp.
  D. 3/. Pasquier, instead of a pin, has placed a circular border be-
hind the socket  of the caustic-holder, in order that he  may not  be
compelled to turn at the same time, both the stilette which is charged
with the nitrate, and the conducting tube,  as in  the process  of Du-
camp.   The other modifications made by this surgeon  are of little
importance, and may be  adopted or  rejected  without  any inconve-
nience.   Moreover, he has disembaiTassed the original method of its
impression-holding  bougies, and  its exploring sounds,  and, accord-
ing to M. Racine, recommends that the treatment should 'be com-
menced with dilatation, by means of ordinary  bougies, in order that 
CAUTERIZATION.
735
we may at the very first, carry the caustic down  to the coarctation
which is most remote.
   E. Some persons have supposed that they could give still greater
facility to the movements of the stilette or mandrin, by giving a greater
length to its outer portion which is metallic, by cutting it in the form
of facettes, in  order that the pressure-screw of the pavilion of the
conducting canula might be better adapted to it, or in dispensing with
the necessity of this screw, by terminating it in a forceps head, one
of the branches of which would be free, and have  transverse grooves
upon it, which  could fix it in a  proper manner into the square open-
ing of the pavilion of the sheath, while the other  would «be continu-
ous with the stilette itself.  Others, M. Dieulafoi  for example, make
use of a canula, which is perforated upon its side, in order that  the
socket, which  is charged with the  caustic,  might  by this  means
come in  contact with the interior of the canal.  These slight modifi-
cations, in my judgment, are of a character not to be neglected.
   F.  The stilette (mandrin) which  I employ  in preference, when  I
do not use the  instrument of M. Lallemand improved by M. Char-
riere,  is a silver one with a platina socket, and  has no border,  but
is furnished with  a button,  and also with a  packet  of silver wire
rolled  round  in spiral  form,  in order to make them flexible and less
liable  to  break.   Its  free  extremity, which is  a  sort of watch-
spring, 12 to  15 lines long,  is inserted  in the fixed  branch  of the
forceps head  which I have  just mentioned, in such manner  that it
may be arrested  in it by a pressure  screw or withdrawn from it at
pleasure.  Its sheath is nothing else than the  flexible  canula of Du-
camp, into which I insert it from behind forwards, but not until after
having curved it, if I consider it necessary, in the same manner as
a stilette  of a  gum-elastic catheter.  The forceps head being  ad-
justed, nothing more remains to be done than  to draw upon it in or-
der to shut up the whole instrument, and then to apply the  button
of its  cauterizing extiemity, over  the  opening of the conducting
canula at the inner end o/ this last.  Its flexibility enables us, by curv-
ing it before the operation, to turn the socket upwards, downwards,
or to the side.  Its head prevents it from making a false route and
secures the caustic from  the action of the moisture of the  canal.
All that  is necessary to make it advance, is to approximate the two
branches of the forceps head by means of the thumb  and forefin-
ger of the right  hand, to attach that which is free  alongside  of the
other in  the pavilion of the  canula, and to push them in  together
while the left hand holds the body of the instrument immovable in
the penis.

                      § IV.—Appreciation.

  The principal  advocates  of cauterization have greatly insisted
upon the necessity of determining not only the distance at which the
contraction is situated, but also its length, thickness, form and posi-
tion.   In  regard to the first  no  difficulty exists.   Any blunt-pointed
bougie whatever  will be sufficient, and  will  give full as much in-
formation as the explorator  or impression-holder of Ducamp.   It
is not the same with the second question.  The emplastic  or gum- 
736
NEW ELEMENTS OF OPERATIVE SURGERY.
 elastic  bougie  charged with soft wax. and which the same author
 advises should be carried down upon all the contractions at the same
 time, with the view of thereby obtaining their various impressions by
 one operation, does not possess the  slightest value.   A long probe
 with a spherical head is infinitely more certain.  This probe, if in-
 serted in the manner of a stilette in a  blunt-pointed catheter, or in-
 troduced by itself, will come down upon the obstacle.  We  then
 mark the corresponding figure  at the  meatus urinarius, if it is not
 marked at the pavilion of the catheter.  It passes beyond  the resist-
 ing  point, which stops  it a little, when we withdraw it, and the
 extent of which by this mechanism may be very easily  measured,
 since we may mark its point of departure  and point of retreat at the
 outside.  The questions of thickness and form present more embar-
 rassment.  The impression-holder of Ducamp is a deceptive instru-
 ment, which deserves no confidence, and which can scarcely subserve
 any other purposes  than the interests of  charlatanism.   Having
 arrived into the urethra, its  moulding wax may be indented full as
 well by the action  of a fold, or spasmodic  movement, or momentary
 flattening of the canal, as by the presence of an actual coarctation,
 and I could never comprehend how upon the evidence of this instru-
 ment alone practitioners of respectability  could venture to have re-
 course to the nitrate of silver.   How many urethras have  been  cau-
 terized without necessity, because the  bougie of Ducamp, when it
 has come out indented, has given rise to the delusive idea that coarc-
 tations existed !  M. Pasquier, therefore, was right in proscribing it,
 and it is an instrument,  in my opinion,  which ought to be banished
 from surgery.  M.  Amussat (Arch. Gen. de Med., t. XIII., p. 294) has
proposed to substitute for it a straight canula, furnished with a stilette
whose extremity, shaped like  the head of a nail  or lentil, shuts up
the opening and constitutes its beak ; but the arrangement of which is
such that the handle is fixed  a little to the outside of the centre of the
terminal plate.  Being  once adjusted in its place, we  hold or cause
to be held the canula immovable with one hand, while with the other
we push forward the mandrin ;  the rasp passes through the obstruc-
tion ;  we then turn it  upon its axis, and its cutting  border later-
ally, immediately projects beyond the line of the sheath ;  in bring-
ing it back we graze the corresponding wall of the canal, whichls
sound and regular  if it encounters nothing, but diseased on the  con-
trary and  contracted  in those cases where  tissues, or a bridle  or a
 crescent-hke projection  arrest the instrument and separate it'from
 the canula   This instrument, which does not materially differ from
 the uretrotome  of  Pare except that it is  straight instead of being
 curved, and  not  less  faulty,  moreover,  than  the bougies of Du-
 camp, would be still more dangerous, and  besides could not succeed
except on very wide contractions   We  shall see, moreover,  far-
 ther on, what necessity there may be of such precautions in prac-
 tlC\t ^Tg S°  ^T? ms^Uments then> ™hich  are  those  which
   ?.   ° Jetfref7ri      apparatus  of M. Lallemand would
 evidently be the best, if it were indispensable to pass in succession
 through all the  contractions where several of these exist   Tb0
 M. Segalas would  possess the same advantages, if it were less mm
pleated.   Finally,  it  is the apparatus  of Ducamp, modified by M 
CAUTERIZATION.
737
 Pasquier, or the instrument which I have made use of, as improved
 by the cutler, Charriere, to which I would  give the preference, if it
 were necessary to adopt one to the exclusion of the others.  But it is
 the same with cauterization of the urethra as  with  all other  opera-
 tions.   In the hands of a skillful person all instruments are  good,
 while in the contrary case there are none that are convenient.
   A. Results.—Whatever may be the process adopted, the charac-
 ter of the  results produced is always the same.  While the nitrate
 is naked in the urethra the patients experience a  pain and sensation
 of burning or broiling, which is obtuse in some   and  very acute  in
 others, and which afterwards continues to a greater or less length  of
 time.  These differences are  owing to several causes: 1st, because
 the cerate, lard or oil which remained about the caustic have envel-
 oped it and prevented it from acting ; 2d, because the indurated tis-
 sues of the contracted circle have almost completely lost their  sensi-
 bility ; 3d, because the caustic comes into contact with some part  of
 the sound tissues and spreads in front or behind the contraction; and
 4th, because  the canal  is already the  seat of an irritation or of a
 greater or less degree of morbid sensibility.   When there has been
 no false route made and the caustic does not run, the pain in general
 speedily subsides, and blood does not always  make its appearance.
 In any event  a general  bath is  useful, in order to prevent the acci-
 dents, and should be had  recourse to immediately or during the course •
 of the day.  When the  coarctation exists to a great extent, or that
 the cauterization has been actively applied, it  may happen that the
 congestion and tumefaction will cause a retention  of urine, which  in
 other circumstances may be produced  by flocculi  or foreign matters
 and eschars that have become arrested in the centre of the obstruc-
 tion.   These are easily removed by a fine  bougie, baths and  tepid
 injections.   Should  inflammation be threatened we  apply leeches  to
 the perineum.   On  the  following, or  on the  second  or  third dav,
 thread-like shreds of a grayish,  blackish or whitish color, issue with
 the urine from  the urethra, and again render this emission considera-
 bly painful.  These discharges, however, do not  necessarily  occur,
 and frequently they are entirely wanting, even  though the cauteriza-
 tion may have  produced  a very decided effect.  It is to be renewed
 as soon as the erethism has subsided, that is to  say, at  the expiration
 of three, four, five or six  days.   In the interval some  persons  apply
 from time to time a bougie for the space of some minutes, and in this
 I think they have reason.   Others  allege that we should not have
 recourse  to dilating  means until after having destroyed the obstruc-
 tion, which  latter requires in this event from four  or six to thirty  or
forty cauterizations, and consequently a treatment of from fifteen days
to three or four months.
  B. Theory.—The partisans of cauterization,  with  Hunter at their
head, maintain  that dilatation «is  nothing but a palliative  means, al-
most always followed by the return of the disease, but that to obtain
a cure free from all danger of a return, we  must not efface and di-
late the induration, but in fact destroy and erode it, which is done by
the employment  of caustic.   After which the bougies come  in  to
regularize and complete the cure. Their antagonists reply, that the
loss of substance caused by the caustic must necessarily leave a hard,
  vol.  iil                     93 
738
NEW ELEMENTS OF OPERATIVE  SURGERY.
elastic, irregular cicatrix, which will almost inevitably reproduce the
coarctation ;  that in this respect  the cauterization is still more liable
to be followed by a  return of the disease  than dilatation, and that
being incomparably more dangerous, it is not understood what should
give it the preference :  and that in order to  act, the caustic-holder re-
quires a canal which still has a width of a line at least, which diameter
always admits of the employment of a bougie, and that these last fre-
quently pass  where the caustic socket cannot penetrate.  Setting out
from the first objection, they demand what advantage there is in cau-
terization, since in all cases where it is applicable bougies may be sub-
stituted for it. and that they ought moreover to precede and to follow
it in almost every case.  These  arguments have not  been triumph-
antly refuted, nor could they be by those persons to whom they are
addressed.   To oppose them it has been found necessary to consider
cauterization  under another point of view.
  Nitrate of silver modifies the vitality of the  parts  touched much
more than it destroys them.  In the urethra, it extinguishes the chro-
nic inflammation which has produced and which almost always keeps
up the contraction, in the same way as it  destroys  a  great number
of inflammations  on the skin, as herpes, zona, and pustules of small-
pox ; in the same way also as it destroys certain anginas, aphthae, oph-
thalmias, &c.  It. is  by this  action,  and not by ulcerating, that it
dries up ancient  discharges, which are situated  sometimes in front
and sometimes behind the bulb of the urethra, and it is by  this that it
has procured such remarkable success in a  great number  of lesions,
which are  independent of all kinds of coarctation.   But  upon this
hypothesis  also,   it  would  be  necessary,  instead  of  attempting  to
ulcerate, destroy, or in  a word cauterize, that we should confine our-
selves as much as possible to the  simple touching of the  parts with
caustic, and to consider the nitrate of silver not as an  actual caustic,
but as a special topical  application, intended to disperse (sufflaminer)
the morbific cause, and at the same time to favor the resolution of the
lardaceous engorgement and the absorption of the matters that have
become effused or concentrated in the laminae of the  mucous  mem-
brane or  subjacent tissues.  From hence  it follows that  the potash
which M. Wathely  recommends, as a substitute for lunar caustic,
is  a dangerous means, which  should  never have  been put in prac-
tice.  We  could explain in  this manner the  results obtained by
the medicated bougies of the ancients, and how it happens that all
kinds of cauterization  have been enabled  to succeed.  With these
principles, and which are those to which I have conformed myself
since the year 1828, (Nivert,  These, No.  100, Paris, 1830,) the em-
ployment of  nitrate of silver becomes a matter of extreme facility
The impression  holders are no  longer of  any  value,  since all that
is necessary  is to introduce the  caustic into the coarctation by any
instrument whatever, without  troubling ourselves to know whether
the obstruction is shorter or longer, or above or below since in dis
solving it spreads itself almost immediately over the entire circum-
ference of the canal.  Also, the conductors which are pierced outside
of the centre of  the platina socket, which caps their  extremity  in
order to separate the caustic-holder from the sound wall of the ure
thra, and to apply it, on the contrary, with the greater accuracy upon 
TREATMENT BY  TOPICAL APPLICATIONS.
739
 the wall which is diseased, thus  lose all  their value.   The bougies
 and  the  caustic  then march  in the front  line;  the first to  dilate
 and enlarge, and  the second to cure and to  restore to the tissues the
 characters which they have in their normal  state.   Thus to dilate at
 first, and not to cauterize for the first time  until after having made
 use of the application of bougies four or five times; to continue the
 dilatation; to cauterize a second, and then a third and  fourth time at
 various  intervals; and to  repeat it even once or twice, though the
 canal has been enlarged to its maximum diameter, in order that we
 may remove the last  traces of inflammation or  morbid irritation
 which may have  remained there; these constitute in fact the  whole
 treatment in a great majority of the cases of organic coarctations
 of the urethra.

       Article VII.—Treatment  by Topical Applications.

   This doctrine induces me to  believe that  the  ancients were not
 perhaps wrong in introducing topical applications  upon coarctations
 of the urethra.   M. Bretonneau,  who  after  combining  sublimate,
 white precipitate, tutty, &c, with ointment,  lard, or wax, besmeared
 a bougie with these preparations, had already persuaded me in 1830
 to introduce them by means of protecting canulas, as far as into  the in-
 terior of the contractions.  Since that period  alum, which was former-
 ly employed, has been again brought into use by certain practitioners.
 M. Legrand (Gaz. Aled., 1836, p. 554) places  it in a groove on the
 side of an emplastic bougie, and in this manner introduces it into the
 urethra; but it is  evident that M. Jobert, (Gaz. Aled., 1836, p. 554.)
 when he confined himself to covering an oiled  bougie with it, did not,
 as he supposed, introduce this substance as far as  the coarctation.
 With a view of treating affections of the urethra in the same manner
 as diseases of the skin or mouth, by pomades or  alum in powder, I
 made use for this  purpose of a very simple  and very certain means:
 I untwist laterally the end  only, or the side  as well as  the  end of a
 wax bougie, in such manner as to form a little cup or gutter there,
 which I fill up with the  medicated  matter selected, and which I im-
 mediately shut by rolling it so as to give it  its original form.  Hav-
 ing introduced it armed in this manner as far as to the diseased part,
 I have nothing  more to do than to turn it on its' axis in an opposite
 direction to its natural  twist, in order  to disengage the medicated
 substance which is thus found in  contact  with the walls of the ure-
 thra.   I have had  every reason to be satisfied  with this process.

   Article VIII.—Contraction resulting  from  a  loss  of  Sub-
                    stance in the Urethra.

   Should the urethra have become  contracted  in  consequence of a
wound, rupture, or any loss of substance whatever, the  cure in gene-
ral is  attended with an extreme  degree  of difficulty.  M.  Denis
 (Journ. Hebdom., 1835, t. II., p. 9,)  finding that the disease in a case
of this kind resisted every remedy,  came to  the resolution to leave a
catheter remaining in the canal.   The cure  in  another  case was not
effected until an incision and  the button-hole cleft was had recourse 
740
NEW ELEMENTS OF OPERATIVE SURGERY.
to, (Journ. des Conn. Med.  Chir., t. III., p. 37.)  The same was the
case in the patient of M. Lefebvre.   I have seen a great number  of
cases of this description.  Dilatation, scarifications, cauterization and
topical applications succeed  here at first, as in  other cases ; but the
urethra will  not  be left alone  three  days  before the disease is
again reproduced.  As  there is in  the cases in question a kind  of
fistulous collar, or track of  a  new formation, and of tissue which is
foreign to the  natural canal, it contracts as soon as it is freed  of the
dilating body and left to itself, from whence it may be conceived how
difficult it must be to effect a radical cure of  a coarctation  of this
description.  It would be to  these cases  only that incision,  as em-
ployed by MM. Arnott, Jameson, Cox, &c, or  excision  of  the  cica-
trix', would in fact be applicable.   The thesis  of M. Mahot (These,
No.  113, Paris, 1837,) will convey a sufficiently correct  idea  of the
coarctation of which  I am here speaking.
  [Organic Contractions  of the Urethra.—M. Cruveilhier  has been
one of the  first to disabuse the public of the erroneous belief, which
had long prevailed, of the frequent existence of various forms of orga-
nic contractions of the urethra.  In a recent work, (Reflexions et Ob-
servations, &c, see Annates de la Chirurgie, No. 14, also Arch.  Gen.
de Med., 3e ser., t. XV., pp. 102, 103.) he  states that he has never
met with but one single description of these organic alterations, viz.,
the fibrous transformation of the walls of the canal of the urethra.
This he says may constitute a mere circular constriction or ring, or
it may have a breadth of from 6 to 12 lines, or even more.   They
may implicate the mucous membrane only, or the entire thickness  of
the tissues  of  the canal.  Most frequently they are situated  in the
membranous, and never in the prostatic portion of the urethra.  The
pre-existence of an ulceration is a more rational explanation of such
strictures, M. Cruveilhier thinks, than a  chronic inflammation,  as it is
difficult to  conceive how the latter could be so  circumscribed in  its
extent.  From these data he deduces the following conclusions : the
inefficacy of forced catheterism  and conical sounds, the preference
of dilatation over cauterization, the necessity of long-continued dila-
tation, the tendency of such contractions to be reproduced, and the
absolute incurability of every kind of urethral contraction.  Other
conclusions resulting from the doctrines of the learned professor, are,
1st, that those contractions described by all authors, and consisting
of a more  or  less complete  valve, or of bridles, or other alterations,
cannot have any real existence ; 2d, that those  barbarous methods of
treatment,  borrowed, apparently, from  the  ancients, and predicated
on the late mistaken  notions concerning this disease, are  hencefor-
ward to be rejected  from surgical  practice ; and 3d, that  all those
complicated and dangerous  instruments invented upon such miscon-
ceptions, must, as a matter of course, be also proscribed
  M. J. Benique, in a recent work, (Reflex, et Observ.  sur  le traite-
ment des  retrecissements  de VUrethre,  Paris, 1844,) also gives the
preference in  these affections, to dilatation over every other process
His method appears to be  reasonable, and to  be full as effectual as
the usual modes, and attended with much less pain.   He introduces
bougies of several sizes rapidly in succession, from small  to  lar™
and leaves them in but  a few minutes, and  thus repeats the operation 
POLYPI OF THE  URETHRA.
741
daily, beginning each day with  the  largest bougie which had been
applied the day before.   M. L. Gosselin, (Arch. Gen. de Med., Paris,
Fevrier, 1845, pp.  175—189,) however, revives the doctrine of actual
spasmodic contractions  of the urethra, as forming a frequent impedi-
ment to the sound  and catheter.  He maintains that there are distinct
circular muscular fibres surrounding the  membranous  portion, and
having a distinct  aponeurotic  investment,  which, with the fibres, are
totally different from and disconnected with the levator ani muscle.
He expresses his  surprise that  they have been overlooked  by the
most  distinguished investigators on these  regions, including Wilson,
Guthrie, Amussat,  Leroy d'Etiolles, Mercier, &c.  He imputes to them
the same or greater power of direct constriction of this portion of the
urethra, the  only part  of  it in which such  fibres  exist, than is
possessed by the bundle of muscular fibres described by M. Mercier,
(lb. loc cit.,) to exist on the lower segment of the vesical  extremity
of the urethra.  These  last constitute there a sort of half sphincter,
which, in cases of organic contraction  in some part of the passage,
is apt to become involved in  inflammation and irritation to such
degree as to  contract with violence and form a valve, which momen-
tarily closes up this orifice and prevents the escape of the urine until
the effort of contraction passes,  through fatigue, into relaxation.
This  then, says M. Gosselin,  is also a  true spasmodic contraction,
but at the vesical termination of the urethra, and to be added there-
fore to the other locality where the contraction, embracing  the entire
contour of the passage, viz.:  the  membranous  portion of the tube,
may, according to  M. Gosselin,  also  take place.   The  surgeon
should be on his  guard in  respect to these nice and yet disputed
points in anatomy while in the employment of catheterism;  and  on
this subject we would also commend to his  study a recent work of M.
Mercier, entitled Recherches  sur  la  nature et  le traitement d'une
cause frequente et peu connue de retention d'urine, Paris, 1844.  It is
to be  farther  noted that M. Gosselin considers that facts do not yet
authorize us to admit that  perfect spasmodic contraction, that is, an
entire spasmodic or temporary muscular constriction and  closure of
the urethra, can take place elsewhere than in the  membranous  por-
tion designated, and also it does not occur there except in cases where
there already exists an organic contraction or a Menorrhagia.  T.]

             Article IX.—Polypi of  the Urethra.

  The urethra of  both  sexes so often  requires  the aid  of operative
surgery, that this  subject of itself could furnish matter for  several
volumes.  I have a remark still to  make on one of its diseases which
are the least known.

                        §  I.—In  Woman.

  In 1825 a  midwife brought to me a lady about 20 years  of age,
who had  had for  some  months  a  pyriform  reddish tumor of slight
consistence and of the  size of  a  small nut,  and which  projected
slightly to the outside by its dilated or rounded extremity, and was
fixed  by its  root  at  the depth of four lines in the urethra.  I seized 
742
NEW ELEMENTS  OF OPERATIVE SURGERY.
 this  polypus with an erigne, drew it a little towards me, and imme
 diately excised it without causing the slightest pain.  On the follow
 ing day the patient found herself cured.  In 1829 I met with a case
 precisely similar.   A woman, whom M. de Blainville had sent to me
 in 1832, furnished a third case of this character.  I have seen others
 in patients of M. Bonis, M. Yvan, M. Demaziere and M. Comet, and
 also  in four or five other patients who were at La Charite,  (Barthez,
 Journ. Hebdom.,  1836, t. II, p. 310.)   M. Wardrop  (The Lancet,
 1828, vol. I., p. 585) has seen three cases of this description.  These
 vegetations in  women  moreover  have  been mentioned by Vogel,
 Rosenmuller, Chaussier, and MM. Lachapelle, Kaldebrand, Prochaska
 and M. Larcher, and everything leads us to believe that excision and
 cauterization,  which I  have always succeeded with, is their true
 remedy.

                               §11.

   Man appears to be equally liable to this species of polypi.  I have
 met with two instances of them. In one the excrescences, which were
 three in number, were scarcely as large as barley seeds.  In the second
 patient, who was a young Englishman, whom  M.  Beaumont asked
 me to see, there was also a number of them and they were still small-
 er.  They were also situated behind the meatus  urinarius.  None
 of them re-appeared after having been broken up or excised.  Do
 not  the polypi  which Nicod has  spoken of so  much, belong to
 this species  of production?   M. Amussat,  (Rev. Aled., 1835, t.  IV.,
 p. 428,) has  found them as far in as at the membranous portion of the
 urethra.   The  small tumor  that  M. Thiaudiere, (Bull,  de  Thirap.,
 t.  VII., p. 240,) took for a pea-shaped cancer, and which was situated
 at the bottom of the fossa navicularis, and repullulated after having
 been  excised by means of an incision upon the dorsal surface of the
 glans penis,  and which disappeared after a second  excision  followed
 by cauterization, was according to all appearance nothing more than
 a polypus of this kind.   The  simple tearing it out and  cauterization
 would have succeeded full as well as the complicated operation of
 M. Thiaudiere.
   [.Polypi of the Urethra.—-It is very clear that this subdivision of
 the nomenclature of polypi, can  be  deemed little  else than the off-
 spring of that  penchant for refinement and innovation,  which is
 caused at the present day  by the great abundance of collabora-
 tors m the held of anatomical  and surgical inquiry.   It is certain
 that we have no very authentic evidence as yet. that polypi, pro-
 perly so called,  ever do  form in the  urethra.  Though it has  been
 asserted  that they frequently do in women,  as by MM  H   Bavoux
 (Arch. Gen.  de Med, Sept.,  1845, 4e ser., t.  IX,  p. 101,)  Asson (lb '
 Oct., 1845, p 235,) S.  Medoro, (//,, p. 236, and^GioritdeiPro.
gressi, Dec, 1844) and  Camm, (lb., loc. cit.,) it is evident  that the
 cases in question by these authors, were for the most part  nothing
 more  than venereal vegetations, so common in the vagina  on the
 glans  penis, prepuce, lips  of the meatus, &c.  T.] 
                      PERINEAL PUNCTURE.                   743

     Article X.—Abnormal Dilatation  of the Urethra.

  In a patient affected with incontinence of  urine, and in whom the
urethra presented a considerable degree of dilatation, M. Hobart, (Rev.
Med., 1830, t. IV., p. 285,) partially excised its lower wall, then re-
united  the wound by means of a suture, and in this manner succeed-
ed in re-establishing the vesico-urethral functions.  A  woman had
her urethra so enlarged, that  she could no longer  retain her urine.
M. Gensoul, (Perouse, These, No. 276, Paris, 1834—Arch.  Gin. de
Aled., 2e ser., t. VIII., p. 121,) by excising a flap from its lower wall
and reuniting the sides of the wound by means of the  twisted su-
ture, also succeeded in restoring this canal to its natural dimensions.
                        CHAPTER  III.

                  PUNCTURE OF THE BLADDER.

   The necessity of making  a solution  of  continuity in the  bladder,
 in order to give egress to the urine, is at the present day so  rare an
 occurrence, that M. Roux, M. Mott, and a number of other surgeons
 of very great experience, have never met with  it.   Since the dis-
 eases of the urethra and the  prostrate  have  become better known,
 retention of urine in fact is a very rare occurrence, and when it does
 take place, the accurate anatomical knowledge which the greater
 part of surgeons of our day possess, enable us almost always to re-
 lieve it by means of bougies or simple  catheterism.   It may, never-
 theless, happen that every other attempt has failed, and that we are
 compelled to choose between forced catheterism and  puncture, that
 is, between two operations which are almost alike dangerous, but the
 first of which cannot be performed  by  everybody.   There are
 three modes of performing the second, namely, by the perineum, rec-
 tum, or hypogastrium.

               Article I.—Perineal Puncture.

  The opening of the bladder through the perineum, in order to
 remedy ischuria, must  have  appeared  a very simple matter to the
 ancient lithotomists, who admitted no other passage for the extrac-
 tion of calculi.  So also was it the first route which was proposed,
and the only one  which  was for a long time followed.  Latta, to
whom Soemmering ascribes  the honor of this  process, is no more
the  inventor of perineal puncture than Garengeot is, who appropri-
ated it to himself a half a  century before.  Riolan  and  Thevenin
formally recommend it, and Toilet had  already performed it in 1681.
 Dionis also describes it quite at length, and shows that it  may be
performed in two modes.  An incision an  inch long upon the raphe,
in the same manner as for  the  great operation, would enable us
to plunge a  long  bistoury into the bladder in front of the anus; to 
•
 744           NEW ELEMENTS of operative surgery.

 introduce a sound here while withdrawing the  cutting instrument,
 and to leave a canula in the wound for the evacuation of the urine.
 But Dionis thinks it would be better, in order to  protect the pros-
 tate, to prolong the incision a little to the outside, as in lithotomy by
 the method of F. Jacques.
   Juncker, Lapeyronie and Heister, suggested almost at the same
 epoch the idea of substituting a long trochar for  the bistoury, and
 they considered that they  had in this manner rendered the operation
 much more simple.   In this respect  it is reduced to the first stage of
 the process for  lateral  lithotomy by Foubert, and it is performed in
 the same manner, that is  to  say, having placed the  patient in  the
 same way as for lithotomy, we plunge the instrument in at the middle
 of the space which separates the ischium from  the raphe, directing it
 a little inwards and forwards  in order  to fall almost perpendicularly
 upon  the side of the  neck of the bladder.  The fear of making a
 false route through so many different  tissues, had  given  rise to  the
 suggestion that we should incise the perineum by means of a bistoury,
 and not employ the trochar until after having felt with the finger the
 distended bladder at the bottom of the  wound.  This is a modifica-
 tion which Sabatier recommends that we  should  apply to perineal
 paracentesis, as Garengeot had recommended it for lateral lithotomy,
 and the  result of which would be that  we should fuse into one pro-
 cess, the methods of Dionis and of Juncker.  But this advice  has
generally been neglected.   While the French writers continued to
recommend pure  and simple puncture,  incision did not cease to be
adopted  in England, where it appears  to have  been performed in
various ways.  M. A. Cooper, following in  the footsteps of Dionis,
incises a  little to  the left of the raphe, depresses the  bulb and then
the prostate to the right by means of his left forefinger, while with a
very sharp scalpel in the other hand he divides the tissues and pene-
trates into the bladder. M. jChas. Bell, when  he thinks he can find
the urethra behind the contraction, lays open this canal as in Chesel-
den's  process of lithotomy, and alleges that in this manner we arrive
into the  bladder  with  less danger.  M. Brander recommends that
we should not penetrate except by incising layer by layer ; but Jones
and Dorsey do not see the utility of so many precautions.   To reca-
pitulate,  if puncture with the trochar  is more prompt, it is at  the
same time less sure.  If the instrument has less danger for  the vessels
and the ureters or vesiculae seminales, and that it would rather sepa-
rate than  divide them, it escapes with greater facility also between
the organic layers, and may more easily miss the bladder.   In using
a long and narrow bistoury we afterwards have to introduce a sound
into the bladder, and then a canula.  The false  routes, though less
probable, are nevertheless  possible, and  the danger of wounding  the
organs, which ought to be avoided, is much more to be apprehended
Incision,  properly so called, which is more rational and  more pru-
dent, i? also  more difficult.  The want  of a conductor, which it is
out 01 our power to pass through the natural  passages,'renders this
process more delicate and more uncertain than in lithotomy, whether
we desire to respect the prostate, as in the lateral method, or whether
we penetrate through the urethra.  Nevertheless,  as  in' such cases
the bladder is very much  distended, and its excretory duct  almost 
PUNCTURE  THROUGH THE RECTUM.             745
constantly enlarged behind the coarctation, I would, if I were ever
under the necessity of opening an artificial passage for the urine,
limit myself to finding the urethra and making a slit between the
contraction  and the anus, even though I had to include the apex of
the prostate in my incision.  This opening would  possess the double
advantage of offering not only a passage for the  sound and canulas
that we might wish to introduce into the bladder, but also of enabling
us to pay immediate attention  to the diseased canal from behind for-
wards.  "The button-hole incision of which I speak, while it is neither
more nor less dangerous than the  ordinary incision for lithotomy, is
certainly less  so than  the other modes of puncturing the bladder,
which, it is  calculated, if I am not deceived, to be successfully sub-
stituted for,  in all those cases in which the morbid or abnormal state
of the perineum does not present any obstacle  to our cutting down
upon the urinary passage through this region.

          Article  II.—Puncture through the  Rectum

   The fluctuating projection which the bladder  forms below the rec-
tum, when it is distended by the urine, is of itself sufficient to suggest
the idea of recto-vesical puncture.   It is even surprising that it was not
sooner thought of, for the finger introduced into the anus  must have
frequently felt  this fluctuation.  Fleurant, who  considers himself to
have been the author of this  operation, and Pouteau, his successor,
with a view of retaining the canula of the trochar in  the  organ,
in order not to be obliged to recommence, if the  natural passage •
should be too tardy in becoming re-established,  bent  the  opening of
the canula of their curved trochar, to a right angle  on the concave
side of its tube.   By this means it is found reversed as it were, upon
the perineal groove, in front of the anus, where it is easy to fasten it
in such manner that it will not interfere with the stools, nor prevent
the patient from walking or sitting.  Most of those  authors who re-
commend leaving a canula in the wound, have adopted the  instru-
ment of the surgeon of  Lyon.  Those who, like Hamilton, consider
that it is better to withdraw it immediately, at the risk of being obli-
ged to repeat the puncture, require nothing more than an ordinary
curved trochar.   It is a matter of little importance, moreover, whether
its point is flattened into the form of a lancet, like that of B. Bell, or
triangular, like the one which  M.  Howship has  endeavored to bring
into repute  among his countrymen.   A narrow bistoury, protected
with linen,  would  effect the  same  object  and would expose less,
perhaps, to  the  risk of fistulas,  and would penetrate better; but
it  is not  so easy to manage, and is less commodious for the pla-
cing of a canula.  The patient, who  is placed in the same position
as for  lithotomy, might, if necessary, rest  with  his belly  upon the
edge of a  bed,  with  his legs hanging down,  did not such a pos-
ture add too much to  his sufferings.   The operator in  that case
would  have no necessity for assistants, and would find himself  more
at ease for  perforating the bas fond of the bladder perpendicularly.
In both cases the forefinger alone, or  the fore and middle  finger of
the left hand, besmeared with cerate,  or any greasy substance what-
 ever, and introduced into the rectum, recognize the projection of the 
746
NEW ELEMENTS OF OPERATIVE  SURGERY.
 bladder and the prostate, stretch the parts, by separating them a little
 from each other, and are fixed with their palmar surface turned  for-
 wards, at a little distance from the gland, while the pulp or the  nail
 rests against the distended organ, after which they serve as a gorget,
 or conductor to the trochar.   This last introduced with the right hand,
 and with its concavity forward, upon  the intestinal side  of  the trigo-
 nus, between the peritoneal cul de sac and the base of the prostate, is
 suddenly plunged in, as if it were with the intention of pushing it to
 the umbilicus, that is to say, obliquely  upwards and forwards.   When
 it has passed through the tissues, and its point has  entered into  the
 bladder, its lateral groove allows some drops of urine to escape, and
 gives us the assurance that we have  not made a  false  route.  The
 stilette is withdrawn ; the liquid runs  out, and the bladder being once
 emptied, the operation is terminated, unless we decide upon fixing a
 tube  in the wound.  In this last case, a flexible catheter, which is very
 pliant, and which should be protected by lint in order by means of
 some compresses, and a T bandage, to keep it immovable  upon  the
 perineum, ought to have the preference to the canula of the trochar,
 which latter,  however,  could  serve  as  a  director  to introduce  it.
 But it is doubtful if a derivative tube would then be necessary.   In the
 patient of Hamilton the  wound  reopened of itself.  In the contrary
 case  a second puncture would probably involve fewer inconveniences
 than  the protracted  presence  of a  foreign body in the  rectum  and
 bladder.  Rigidly considered, it would be at least useless to leave the
 canula beyond the time necessary for the cohesion of the tissues, that
'is to  say,  beyond the space of 12 to 24 hours ; for the inflammation
 which takes place in the little wound  does not after that permit  the
 urine to become infiltrated into the tissue of the recto-vesical septum,
 while at the same time it opposes no serious obstacle to its  escape.

              Article III.—Hypogastric Puncture.

   The principles  advanced  on this  subject in  the  last  century by
 Hoin and Noel, prove that puncture above the pubes, which must
 have originated at the same time with hypogastric lithotomy, had  not
 yet found but a very small number of  partisans.  Tolet, Drouin, Tur-
 bier,  Mery, Morand and a few others were, according to M. Belmas,
 the only persons who practised  it.  But the authority of  F. Come,
 Bonn and Paletta, and especially that of Soemmering, who declared
 himself its unequivocal  champion,  ultimately brought it into vogue
 throughout all European spite of the efforts of Murray and  Mursinna
 to bring into  repute recto-vesical puncture.  It was almost the only
 puncture employed in France for a  long time.  The case of punc-
 ture by the rectum found in the thesis of M. Duplat, and the two exam-
 ples  which M. Cabanellas has cited from the practice of M. Magnan,
 are exceptions which passed unnoticed.  As the straight trochar which
 was  first  employed might wound, and as the point of its canula left
 remaining might  ulcerate the posterior  wall of the bladder, which
 necessarily contracts upon itself after the  evacuation of  the' urine
 the curved trochar of F. Come has been generally adopted, whether
 we confine ourselves to puncture without previous incision or in im-
 itation of Abernethy,  divide the  hypogastric wall with the bistoury 
hypogastric puncture.
747
before having recourse to the trochar.   The operation, moreover, is
so easy that the preparatory incision is in reality only calculated to
embarrass it.   The  patient is to be placed  horizontally on the  long
edge of his bed.  The surgeon first looks for the upper border of the
pubes and the median line ; he then directs the point of his trochar to
a point about an inch above the symphysis and plunges it with a single
movement from above downwards and from before backwards into
the bladder, where he  arrives after having passed through a space
which varies according to the embonpoint of the patient and the par-
ticular arrangement of the parts.  The stilette having been withdrawn,
the urine escapes, and the  canula,  which is to be shut  up with a peg,
is afterwards fastened  around the  body by means of cords which are
attached to the lateral parts of its pavilion.  But this canula is still
more dangerous above the  pubis than in the rectum.  If it is too long
it ulcerates the organ ; and if too  short, its  point having been left by
the bladder which contracts upon itself, becomes arrested in the sur-
rounding cellular tissue.  If it  is  not changed  from time to time, it
may become encrusted with calculous concretions, by which its remo-
val will  be attended with difficulty.   After having withdrawn it, it
is not always an  easy matter to place it in  again.  As a gum-elastic
sound introduced into the bladder through the metallic canula and
left there in place of this last, is of a smaller diameter, it would  not
completely fill up the wound and would therefore allow the urine to
filtrate between  the tissues and  the  foreign body.   The flexible
sheath serving as  a chemise to the instrument, and which M. J. Cloquet
introduces at first, in such manner  that  in withdrawing the stilette, to
allow the urine to escape, and afterwards its canula, it is found alone
in the solution of continuity, is but an imperfect remedy for this diffi-
culty.  It  has to  be shorter than the silver tube, on the external sur-
face of which its lower extremity always forms a  projecting  cir-
cle  which is more or less  irregular, whatever care we may  take to
attenuate and regularize it.  From wThence it is, that there exists a
series of projections or borders, rendering it more difficult to push it
through the tissues.  Moreover it  would be incorrect  to suppose that
a tube, whose circumference is exactly fitted to the contour of the open-
ing through which it has passed, would for any length of time remain
in this precise contact.   After  the expiration of a few hours this is
already  found  to be no longer the case, and  the  fluids  pass with
facility between the canula and the wound.   The bougies and sounds
in the urethra daily afford evidence of  this, a fact which I also again
saw in the patient, who, in the year 1822, at the Hospital St. Louis,
contrived the modification of which I  have  just spoken.   Such con-
siderations all go  in support of the  practice  of those who do not con-
sider it proper to  leave any thing  in the wound, and who. when cir-
cumstances make it necessary, prefer to repeat the puncture as soon
as the bladder is again distended.   I would  be wholly of their opinion
if the puncture of the abdominal walls, which agglutinates more rap-
idly than that of the bladder, did not expose to  the risk of the filtra-
tion of a few drops of liquid into  the  pelvic cellular tissue, and if
after the  expiration of about twelve hours  the  inflamed state of the
wound had not already transformed it into a sort of fistula.  A patient
in whom  I had recourse to  puncture twice in the space of three days, 
748          NEW  ELEMENTS OF  OPERATIVE SURGERY.
died on the sixth of a peritonitis.  A dark colored collection of small
extent was found  between the  lower  part of the hypogastrium  and
the front part of the bladder.  A case  of hypogastric puncture of the
bladder,  however, related  by M. Franc, (Extract des Calculs. &c,
p. 5,) was not followed  by any accident.  This puncture, which was
successfully performed in 1828, by M.  Vaust, (Alem. de VAcad. Roy.
de Mid., by M. Voltens, Dec, 1838,)  was again repeated on the same
patient, by M. Voltens, (Ibid., Dec, 1838,) in 1834.  The patient ope-
rated upon wears a gum-elastic catheter and experiences no inconve-
nience from it.   He was afterwards operated upon at the perineum
and  his urethra appeared to have closed up.  M. Nick, (Gaz. Med..
1839, p.  185) relates the case of a  man 72  years of age, in whom
hypogastric puncture was performed to relieve an ischuria, and who
was  obliged to wear a canula up  to  the  time of his death, which
took place at the expiration of twelve  years.

  Article  IV.—Parallel between  the  Different Kinds op
                          Punctures.

  The three kinds of vesical paracentesis  have each in turn been
eulogized or proscribed to the exclusion of the others, and as usual
in such cases, the accurate truth of the matter has almost  always
been infringed upon.

                              § I.
  Recto-vesical puncture, without being  as formidable as Soemmer-
ing alleges  it to be, is  far from  being as innocuous as Murray  and
Schmucker (Rougemont, Bibl.  Chir., p. 40,) consider it.  Tumors
in the neighborhood of the anus, and also the thickness of the  septum
at the entrance of  the intestine, may render it painful, or its  execu-
tion uncertain, or even impossible.   The instrument may escape be-
tween  the  bladder and  rectum into the pelvic  cellular  tissue, or it
may perforate the peritoneum  when  this  membrane  descends  too
near the prostate or if we puncture a little  too high, or if we go too
far down or to the side, we may wound the vasa deferentia and the
vesiculae  seminales, or  even the ureters.   As the organ is  incised
very near the urethra, and consequently near the seat of the disease, we
incur the risk of aggravating the accidents in this respect.  Finally,
the wound may remain fistulous, and allow the stercoral  humidi-
ties  to enter into  the bladder and  produce fatal consequences    It
is true that the  greater part of these difficulties will in most cases
be overcome by a skillful hand, and that the dangerous consequences
which I have just mentioned are not all unavoidable; but the fistula
which the  address and intelligence  of the operator cannot  prevent
taking pjace, as is proved by  the  cases related by  Bonn,  Paletta,
Angeh, &c, is alone of itself a very serious disease, and the  cure of
which is attended with too much difficulty to allow us to run  the risk
of its occurrence when it is possible  for us  to avoid it   In exchange
for so  many inconveniences puncture through the intestine  has the
advantage  of being generally easy,  of penetrating the bladder at its
most depending point, of traversing only  a small extent of tissues
and  such as are too condensed  to lead to  any serious apprehension 
PARALLEL  BETWEEN THE DIFFERENT PUNCTURES.       749
 of the infiltration of urine or abscesses, which however have been
 sometimes seen to  take  place, especially in a patient mentioned  by
 M. Nauche;  the advantage  also  of giving  facility to the use of a
 canula, in the manner recommended  by Schmucker, (Rougemont,
 Bibl.  Chir., t. I., p. 40,) and of not absolutely confining  the  patient
 to his bed:  a case of a man is related,  who  had  undergone this ope-
 ration twenty times without experiencing  any accidents from it,
 (Bull, de Fer., t. XII., p. 240.)

                               §  II.

   The supra-pubic puncture is not applicable when the  retention is
 caused by contusions or inflammation, or by tumors in the hypogas-
 tric region.   It must expose more than any of the others to the risk
 of infiltrations and urinous abscesses.   As the bladder is opened upon
 its anterior surface, it cannot empty itself without difficulty, and does
 not so well  support the presence of a canula.   Sometimes we are
 obliged to penetrate to a great depth to find the organ, and the peri-
 toneum  is  not always safe from danger.  There are  however
 no fistulas to be apprehended, and even though the wound should
 take on this character, we should have no reason to be alarmed with
 it.  As  the  peritoneum is  crowded  back  and  separated  at  a dis-
 tance from the pubes by the  force of the  distended bladder itself, it
 may be easily avoided, and it is almost  impossible to miss  the bladder
 in plunging in the trochar.   The operation, which is still more easy
 than by the rectum, is not more painful than paracentesis abdominis,
 and is performed upon a region which has not become altered, and
 which is  therefore  less  irritated or less irritable than the diseased
 part.
                             § III.

   Puncture through the  perineum is incomparably less certain than
 at the  hypogastrium, and endangers the vesiculae seminales and ure-
 thra in the same way as puncture at the rectum.   It may strike too
 far forward and between the pubes and bladder, or too far back-
 wards, and  thus penetrate into  the peritoneal cul de sac or into the
 intestine, and  thus not arrive into the  distended reservoir until after
 having lacerated their walls.  Nor are the vessels of the  peritoneum
 or the  prostate safe  from the instrument.   Infiltrations and abscesses
 are not altogether impossible, and  in no region is the  presence of a
 canula more irritating.   The only advantages of this  puncture are,
 that it opens  into  the  bladder  upon  a  depending point, without
 exposing to the risk of fistulas as  that by the rectum does ; of making
 a readier passage for the urine,  without  incurring as  much risk  of
 urinary inflammations  as puncture at the hypogastrium.   Such ad-
 vantages,  though small in number, are important; and if we had not
 to purchase them at  so dear a price, or if they were actually of any
 great value, perineal puncture ought perhaps to  be preferred  to the
 other two modes.  Now it appears to  me that a simple button-hole
incision at the urethra possesses  these advantages in a still higher
degree, and that it even enables us, almost with a degree of certainty,
to avoid all the neighboring  organs.   As it  has  no other inconve- 
750
NEW ELEMENTS OF OPERATIVE  SURGERY.
niences than that of being a little more delicate, and somewhat  less
prompt, I consider it preferable in all cases where the form or con-
texture of the perineum is not  too much changed from the normal
state, and where the surgeon has some-experience  in operations.   In
the other cases supra-pubic puncture should have the preference, and
recto-vesical puncture would  be reserved for exceptional cases, and
would  not  be had recourse  to except  in  those instances in which
some particular obstructions were interposed  to the introduction of
the instrument through the two principal passages.

                             § IV.

  As to the method  of penetrating from before backwards, through
the symphysis, as M. Brander recommends, and states that  he has
practised, and as Meyer  is said to have (Rust's  Handb. der Chir.,
vol. XIII., p. 85) advised in cases of retracted  bladder, it  is doubtless
one which can find but very few partisans; in  the first place, because
in taking the adult age into consideration, it would in  most cases be
impossible;  and in the second place, because it would not protect us
with greater security from infiltrations than hypogastric puncture.

                             § V.

  In the same way also that  it would be rash to  have recourse to
puncture in  the bladder without some very positive indications, as it
would  be, for example, in cases of retention  caused by a mere spasm
of the  vrethra, two cases of which are related by M. Racine, and in
those alleged spasmodic contractions  which M. Holbroock still ven-
tures to point out to the attention of practitioners; so  also should
we aggravate the danger of this operation  if we waited too long.
In a patient who has  not  urinated  for  the space  of 24, 36, or
48 hou-s, the bladder  having become distended  to an extreme
degree, may  become eroded  or  even  burst.   The pain,  fever,
and  escape  of a portion of  the urine into the  general  circulation,
would, under such  circumstances, soon place the patient  in so
alarming a situation that puncture could no longer save his life or pre-
vent a  number of accidents which would not probably have followed
it a  few days sooner.  The case which fell under my own  notice,
and v/hich I just cited, is another evidence of this.
                       CHAPTER IV.

                      URINARY FISTULAS.

             Article  I.—Recto-Vesical Fistulas,

  Recto-vesical fistulas, which are equally as obstinate as those of
the vesico-vaginal septum, are moreover treated  precisely in the
same manner and by the same processes. In these cases however 
FISTULAS OF THE  URETHRA.
751
the surgeon begins, if the urethra is contracted, by restoring it to its
natural dimensions;  by depressing the prostate with  the redresseur
of MM. Tanchou, Leroy or Pravaz, should its  size  be  such as to
interfere with the passage of the urine; and  by  destroying, in fine,
the  obstructions  that the  bladder encounters in evacuating itself
through the  natural passage.  Desault cured recto-vesical fistulas,
following the operation  of lithotomy by incising the parts situated
between the wound of the perineum and that of the  intestine, com-
prising in this incision the sphincter of the anus, in such manner as to
transform the whole into one single wound.  But if the first incision
had  been cicatrized  for a long time, this process would, be no longer
applicable  or would at  least  require  some modification.  In such
cases we might imitate with advantage the conduct of M. A. Cooper,
who again laid open through the perineum, upon a grooved sound the
prostatic portion  of the urethra from before backwards, in order that
the urine, finding a means of escape anteriorly, might allow the pos-
terior opening-to close up, in which operation  he  succeded  perfectly
in one  instance.   The incision with the bistoury, extended from the
fistula to the perineum  and  on the  groove of a  sound, as  in recto-
prostatic lithotomy,  would be more easy and  more certain perhaps
than  the oblique  operation  of  Desault, should  the  process of M.
Cooper not appear to be sufficient, but it would expose to the risk of
wounding the verumontanum and the ejaculating ducts.  In a youth
14 years of  age,  a rod  of iron, which had penetrated  through  the
anus, laid open the bladder to a great  extent.   Two years  after, M.
MacFarlane, consulted by this patient, (Arch.  Gen. de Aled., 2e ser.,
t. II., p. 281,) had recourse to cauterization, and effected a cure in
the space of two  months.  The same surgeon  mentions a child of 12
years, whose  bladder had been wounded by  the thrust of a bull's
horn, and who was not over six weeks in getting  cured of his fistula.

                 Article II.—Internal  Fistulas.

  Fistulas of the kidney, or ureter, or on the apex or sides of the blad-
der,  and which do not open externally, but discharge into the intestines
beyond the reach of  instruments, can expect no relief from  surgery,
except in so far as they should depend upon an obstruction, calculus,
or coarctation, for example, which might be removed or destroyed.
Fistulas of the umbilicus, from the urachus continuing open, are cases
of this kind.

            Article III.—Fistulas of  the Urethra.

  It  is not altogether the same with fistulas  of the urethra, as it is
with the fistulas  in the preceding cases.  In the corpus  spongiosum
they rarely fail  to disappear spontaneously "as  soon as we have
adopted the  precaution  of re-establishing  the  dimensions of this
canal.   At the fossa navicularis, where M. Barthelemy, (Bull, de Fir.,
t. XIX., p. 74,) has seen  them open in  the manner of  the spout of a
watering pot, they may almost always  be dried up by  not permitting
the patient to urinate for  some days except by means of a  catheter,
as was done  by  this  surgeon,  in adopting also the precaution  to 
752           NEW ELEMENTS OF OPERATIVE  SURGERY.

place the finger behind the glans penis, in order to keep the canal ac-
curately applied against the instrument, every time  that the bladder
was emptied.  I have, however, failed with this process in two cases of
exceedingly small fistulas which were situated, one on a line with the
fossa navicularis, and the other at a few lines behind.   Fistulas from
defect of original  conformation may also exist  in this place.   In
a subject for  dissection, M.  Labat,  (Gaz. des Hopit., 1839, p.  135.)
found  that  the ejaculating ducts, after having passed through the
prostate, united together above the  urethra, so as  to  form a single
canal which afterwards ran through  the whole length of  the  penis,
and then opened externally above the meatus urinarius.

                §  I.—Injections.—Cauterization.

  The fistulas in the bulbous, membranous and  prostatic portions,
which are the most frequent and the most  obstinate,  are  therefore,
so to speak, the  only ones  which  require a special examination.
Whether they have one or several external openings, or whether they
are sinuous or direct, or go to terminate far from their point of de-
parture, either near the scrotum or in the  groin, at  the breech, or in
the anus, or on the  inner side of the thighs, or at the  extremity of the
labia majora in women, or  at the perineum, the first and  frequently
the only thing to be done  is, to explore the urethra and  to destroy
the coarctations, should any be met with.   If  they persist after this
preliminary  treatment, we must have recourse to injections that are
made irritating by means of alcohol,  vinegar, or dilute mineral acids,
or to cauterization, by means of nitrate  of silver,  or crayons of mi-
nium, or with nitrate of mercury, or  to compression, in a word to all
the various  medications  proposed against fistulas  in  general, and
which  enter into the domain  of surgical pathology,  properly so call-
ed.   If they still resist and are sinuous, we excise them in order to
lay bare their bottom;  after which there are no other remedies by
which to effect their cure than derivative catheterism, together with
additional cauterization and the suture.  Some yield to no remedy,
but ultimately in the course of time get well of themselves.  A phy-
sician  who  had exhausted  all the resources  that had been recom-
mended to him by Boyer, Dubois, Dupuytren, and MM. Richerand.
Roux, Marjolin, Cloquet and myself,  presented a remarkable  exam-
ple of this kind.
                              § II.

  Derivative catheterism can scarcely succeed except in those fistu-
las which are  unattended with, or have but a very slight loss of sub-
stance, whether they have or have  not been  preceded  by contrac-
tion of the urethra.  The gum-elastic catheter left to remain  in, is
not always unattended with inconvenience, which may be said also of
the metallic  S shaped catheter, which was used by J.  L. Petit, the one
with a fixed  curvature as  recommended  by  Hey, or that  which
is strongly curved as Physick advises when the prostate is  engorged,
as also of that wh;ch has a free direction, like  the  one generally em-
ployed in France since the  time of Desault.  If it remains open in
order that the urine may escape in proportion  as the ureters deposit 
FISTULAS OF THE  URETHRA.
753
it in the bladder, its point  presses against the posterior wall of this
organ, and irritates, and ulcerates, and sometimes even perforates it.
If it is kept shut up, a small quantity of the urinary fluid, which al-
most constantly makes its  escape between it  and the walls of the
canal, will be found sufficient in many cases to prevent the fistula
from becoming obliterated.  This is a fact which has been perfectly
well demonstrated by Asselin in his Thesis in  1803, and which is
confirmed by the experience of M. Caffort.  It is, consequently, bet-
ter to catheterize the patient,  or  for him  to learn  to  do it  himself,
with a silver catheter in preference, as often as  he is under the ne-
cessity of urinating.  A patient whom I had in vain submitted to the
use  of permanent  catheters,  at  La  Pitie in  1830, was radically
cured at  the expiration  of three days, as  soon  as I  decided upon
catheterizing him every four or six hours, and then immediately re-
moving the instrument.  Cauterization  may be  combined with ca-
theterism, and becomes indispensable as soon as the cure is  delayed
beyond a week or  two.  If after six weeks or  two months  the dis-
ease continues, we  may, without fear of being charged with precip-
itation, have recourse to the final expedients.

                              § III.

   The button-hole  incision, which in a case of necessity might be
applied to urinary fistulas of the penis and scrotum, is  an operation
which is eulogized by M. Viguerie, (Journ. Hebdom., 1834,  t. I.,  p.
183,) but  which has, however, nothing very conclusive in its favor.
To incise the  urethra at  the perineum, in order  to  cure openings
which exist in front of it, has  undoubtedly something very plausible
in it; but besides that it is  not always an  easy matter, the cases of
M. Viguerie himself prove that we thereby establish a new fistula in
the patient,  and one which we cannot get rid of  at pleasure.

                             §  IV.

   The suture is applied here in the same way as in any other region.
We commence by transforming the fistula into a button-hole  incision,
or one which is somewhat elongated, but  less  so on the wall of the
urethra than at the  integuments.   After having  abraded its  borders,
removed the callosities, and approximated the two lips upon a flexible
catheter,  which is  destined to  remain in place, we keep  them  in
contact by means of a sufficient  number of points  of twisted suture,
which points should not be more than three lines apart, if we do not
wish the  urine to  infiltrate between them, and  which, for the same
reason, ought to  be  tightened sufficiently if we  wish the  aggluti-
nation to take place wholly by first intention.   We afterwards fill up
the perineal depression with compresses or lint, in order to  support
the whole by a gentle compression.  If everything goes on well, we
remove the  needles on the  fourth or fifth  day, beginning with those
at the angles.   The other is left  in a day or two longer.  This, in its
turn, is  removed, and the  patient will be found to be  cured.  M.
Cloquet has been successful in one case  of this kind, (Journ.  Heb-
dom., t. IV., p. 45.)  Unfortunately we have not always as happy  a re-
  vol.  in.                    95 
754
NEW ELEMENTS OF OPERATIVE SURGERY.
suit, as is proved by the fruitless essays of Chas. Bell.   It frequently
becomes necessary to repeat the operation several  times ;  also it is
not unusual to find that all the efforts of the  surgeon, and all the per-
severance of the patient, result in nothing more than an enlargement
of the fistula.   I have  elsewhere mentioned what  uretroplasty (see
Vol. I.) in vain attempted, by M. Green, (The Lancet, vol. II., p. 669,)
has obtained, up to the present time in the hands of MM. A. Cooper,
Earle, Alliot, &c   M. Dieffenbach, (Rev. Aled., 1826, t. IV., p. 123
—Arch.  Gen.  de Med., 1836 1837,) after making  trial of cauteriza-
tion by  itself,  suture  after cauterization, abrasion and interrupted
suture," abrasion  and twisted suture, suture of a fold of  the  skin,
the borders of which were  united  over the fistula, and also of cir-
cular strangulation of the contour of the ulcer, has, by submitting  the
fistula at last to a final test with  the suture, anaplasty and cauteri-
zation under all their forms,  succeeded in some instances; but he  has
also seen a great number of urethral fistulas, and even such as  were
of the smallest  kind, that  have obstinately  resisted  all his efforts,
and persisted in continuing in spite of every remedy.

                   Article IV.—Hypospadias.

  Urethral fistulas from birth, somewhat near the glans penis, require
no other  remedy than the creation of a new  canal  in the tissues of
the penis, by which  process M. Rublach (Bull, de Fir., t. X., p.  159,)
states that he succeeded in one instance.  In a case of a very  large
fistula, which  formed under the  glans  penis, in consequence of an
.ulcer, M. Heller (Gaz.  Mid.,  1834, p.  747,)  divided  the bridle
and abraded  the sides of the incision, then inserted seven points
of suture, and thus completely succeeded.  M. Perrin, (Arch. Gen. de
Med., April, 1839, p. 485,) in order to cure a hypospadias, caused by
an ancient stricture of the urethra, confined  himself to the  excision
of the prepuce and  pendant  portion of  the glans.   A child  8  years
of age, who had brought on a hypospadias by constricting his penis,
was cured  of  it by  M. Pauli, (Gaz. Aled., 1838, p. 807,) by means of
excision  of the prepuce, and by  detaching  the integuments of  the
penis, and then inserting  six points of suture.   As to hypospadias,
properly so called, I am not  aware that it has been often treated by
an operation.   The abrading of the sides of the furrow which pro-
longs it in front, then detaching them a little, in order to bring  them
to the median  line, and afterwards uniting  them  by suture upon a
catheter, which is to be left in the urethra, would enable us, per-
haps, to effect a cure in some instances ; but I doubt if the hollowing
out  of  a new  canal  through the glans penis, either  from before
backwards or from  behind  forwards, would  present much  prospect
of  success.   Moreover, we  should not  be  justified in attempting
such  operations,  except  only at  the period  of puberty or in  adult
age.  M. Begin, however,   (Elem. de Chir., 2d edit., t. I., p.  -565,)
like M.  Rublach, had recourse to it in a child who urinated only
through a capillary aperture, situated at a finger's breadth behind the
fossa navicularis.  A probe  having been introduced into the passage,
and directed towards  the  glans, a hydrocele  trochar  was applied
to the point where the meatus ought to have  existed, and plunged in 
HYPOSPADIAS.
755
until  it came in contact with  the probe.   The canula was left in,
and on the day after a gum-elastic conductor  of Ducamp was sub-
stituted in the place of this. The fistula, after being cauterized, cica-
trized, and the  cure was the result.   Might we not, says the same
author, (Ibid., p. 563,) apply to hypospadias the following process:
abrade the borders of the gutter of the penis, by detaching the skin
on each side; and then reconstruct for the canal  a lower cutane-
ous wall, either by means of elongating the skin, and uniting it upon
a  catheter,  or by taking  a flap borrowed from  the neighboring
parts, and brought down upon the penis ?   This suggestion has not
been tested in practice.
   \Cure of Hypospadias.—It was M. Ricord who invented the in-
genious process for the cure of a hypospadias, or destruction of the low-
er wall of the urethra, to the distance of three centimeters from the
meatus, and which interfered with erection.   He made a small in-
cision into the membranous portion and  passed  the urine off by
means of a catheter through this artificial route, until by abrading
the lips of the defective portion of the passage  and  uniting them by
suture, he had effected their agglutination.  The case (Arch. Gen.,
3e ser., t. XL, 1841, p. 109,)  completely succeeded,  and the  incision
into the membranous  portion soon healed up.   The erections after-
wards took place without difficulty.   The dangerous point in this
process is that of closing up the new or temporary aperture, and also
the risk of urinous infiltration, as well as  the exposure to a greater
number of accidents from having two wounds under treatment in
the same organ.
   Foreign bodies in the bladder and urethra.—Modern surgery in
its minute researches has added one remarkable fact to the chapter
on foreign bodies  in organic cavities,—or at least a fact which, had
it ever occurred before, has hitherto escaped observation.   Dr. Ar-
taud, (sitting  of the Acad. Roy. of Medicine,  Paris, Jan. 27, 1845,
Arch. Gen., Fev.,  1846, pp. 213-216.) on ascertaining, at Cherbourg,
in May, 1840, from a female  unmarried  patient  aged twenty-six,
troubled with amenorrhea, and  burning pricking  sensation in  the
kidneys and  urinary passages, with numbness along the right crural
nerve, ischuria, &c, that she had passed  a worm (strongle geant)
with her urine, catheterized her and after withdrawing a large quan-
tity of lactescent whitish urine, found  the retention of urine, on the
following morning, complete.   On catheterizing again he perceived
a  foreign body, and  substituting Hunter's forceps, cautiously  ex-
tracted a reddish colored flattened worm,  (twenty-two centimeters
long  and four millimeters thick.)  Near a year afterwards on  the
recurrence of similar accidents, he extracted in the same manner a
fleshy body of the size of an almond, and during the ensuing eight
months, fifteen of these  bodies of various  size, and also seven more
strongle worms.   Finally, by aid of dilatation, he seized and brought
out another fleshy body of the size of a large chesnut, pierced in its
centre and containing five smaller bodies  in its cavity.  Syncopes,
hysteria and  hematuria,  with some pain in the right lung and  he-
moptysis, succeeded, with intense fever and delirium.  About eight
months after  the  suppressed  catamenia were imperfectly resto-
red, when a false membrane  thirty centimeters  long, forming  a 
156
NEW ELEMENTS  OF OPERATIVE SURGERY.
 cylindrical tube, (conduit cylindrique,)  large enough to admit the
 finger, came out spontaneously from the urethra.  She now enjoyed
 good health for several months, until in the latter part of 1841, when
 the symptoms again  returned, and  she again passed three strongles.
 She was, however, still living January 27, 1845.   (lb.)
   M. Segalas, in his report to the Academy, as one of the commis-
 sion on  this case and its  specimens, confesses, while admitting the
 facts as incontestable proof of the generation of  strongles geants in
 the urinary organs, their inability to explain the fleshy bodies, (masses
 charnues,)  whether they were the residuary of organized fibrine from
 hemorrhagic deposits, or portions of the substance of  the nearest
 neighboring muscles, detached by the verminous affection.  In refer-
 ence to  the last branch of this  question, M. Segalas  alludes to the
 case of three worms, two to seven inches long, found imbedded (lar-
 des) in the  substance of  the lumbar muscles,  also  to a strongle geant
 found by M. Blainville in the kidney of a weasel,  (marte,) and which
 was over twenty-nine inches long and two and a half lines broad, and
 only half a  line in thickness.
   The suppression of the catamenia appears, in our  judgment,  to
 furnish a satisfactory explanation to most if not all of the phenomena.
 The discharge of  regularly organized false membranes, during the
 violent, sharp,  bearing down  pains of the paroxysms of dysmenor-
 rhea, which recur just anterior to the menstrual period, is no uncom-
 mon event  in unmarried  young women in whom the  catamenial
 function continues to  be but imperfectly performed.  In one remark-
 able case I attended, of a married colored  female, in the Bahama
 Islands, and in whom this affection had existed for years, the bearing
 down pains were excessively acute, and  more so  even than those  of
 severe labor, from which in fact they were scarcely distinguishable.
Enemata of laudanum, injections of the same into the vagina, and
large doses internally, with the hot bath,  &c, scarcely procured any
relief.  Little  or no  menstrual blood would come away at these pe-
riods, and in the  intervals there was more or less of the usual sub-
 stitute, fluor albus.   But the great effort of nature  to make up for the
deficit, and  in this case an anxious  desire also to  become impregna-
ted, explain perhaps how the violent contractions  of the womb aided
in separating the fibrine  from the other  portions  of the  blood con-
tained in the vessels on the inner surface of this cavity, and in thus
 forming the abnormal membrane.  The case of Dr. Artaud in ques-
tion, exhibited  this same abnormal organized membranous formation,
in fact a tubular  one corresponding naturally to the cylindrical shape
 of the urethra, as the same finger of glove-like tubes of membrane
 are seen  in  croup, dysentery, &c.  (See also  our note on this subject
in Vol. II. of this work.)   The same diseased action which made the
 urethral cylinder, may very readily explain the fleshy  fibrinous de-
 posits expelled or extracted from the bladder.  And were in fact the
 supposed strongles geants anything more than one of the urinary
cylinders as it were  consolidated ?  Therefore not  worms, but  all
 morbid products of the  same  altered  condition of the blood, (i  e
 highly surcharged  with  fibrine and gelatine,) from the  suppressed
 and retained catamenial blood, however true  it may be that the con- 
IMPERFORATION.
757
dition of this latter recrementitious and quasi venous fluid in its nor-
mal state is such that it does not coagulate out of the body.
  Three inches of a gum-elastic sound,  which  had broken off and
slipped  into the bladder in  a man  aged 50, December,  1836, (Dr.
Buchanan,  in London Lancet, July, 1840,)  after occasioning much irri-
tation and purulent discharges from  the bladder  and urethra, for the
space of over a year, finally made its way in three  successive por-
tions at the meatus, from whence  they were extracted  by means of
the forceps and probe.
  In the case of a young man aged 25, who while playing with a
metallic tube which he had introduced into the urethra, let it slip into
the bladder, together with the pen within the tube, M. Dieffenbach
(Caspar's Wochenscrift, 1843, No. 1) was obliged  to make a small
puncture above the pubis before he could*extract it.  We- cannot
however conceive why this surgeon should have  first found it neces-
sary before making the  puncture, to  resort to the  lithotritic  forceps
passed through the urethra, in order  to hold the tube in a fixed posi-
tion.  This part of the manipulation appears to us to have been quite
unnecessary, as one end of the tube probably could have been so se-
cured by two fingers in the rectum, as to make the other project above
the pubis, and thereby designate the point to cut down upon with the
bistouiy.   The more important was it not to make any uncalled for
irritation in the bladder itself, from the  admission by M.  Dieffen-
bach himself; that he preferred a simple  supra-pubic puncture with
the bistoury to the operation of lithotomy at the perineum or rectum,
because, as he says, of the greater danger of this operation in cases
of foreign bodies that have been introduced into the bladder.
  M. Leroy d'Etiolles, by means of lithotritic instruments, succeeded
in breaking and extracting from the bladder of a woman (Arch. Gen.,
Aout, 1844, p. 522) a round  piece of wood, 93 millimetres long and
10 to 11 mill, in diameter.  It occupied a transverse position.   T.]
     PART  NINTH.

DISEASES OF THE  RECTUM.
                         CHAPTER I.

                  DEFECTS OF CONFORMATION.

                   Article I.—Imperforation.

  We sometimes find in young  girls that the rectum opens into the
vagina, or near the posterior part of the vulva, instead of terminating
with an anal opening in front of the coccyx.  Still more frequently
we find  in new-born children of both sexes, that the intestine ends in
a cul  de sac above its natural termination, and at a greater or less
height in the pelvis.  The first case, which belongs to the varieties of 
758
NEW ELEMENTS OF OPERATIVE  SURGERY.
artificial anus, is, all other things being considered, not so necessarily
fatal as the second.  The meconium extravasated into the bladder be-
comes diffused there and may be expelled from it  during the course
of a few davs.   An infant whom I saw, and who evacuated it by the
urethra, lived for the space of several weeks.   The opening, how-
ever, from the  depot  of fiscal matter, and the canal by  which it
is excreted, are not in such cases sufficiently large for life to be sus-
tained when the matters have  attained a certain degree of consist-
ence, and so much the more so because the urinary organs are not
capable of supporting  for a long time and without  danger the imme-
diate contact of stercoral substances.   I have seen the anus in three
instances open into the urethra, and  in two into  the bladder.  M.
Bonet,  (Revue Med., 1829, t. II., p. 398,) M. Willaume, (Journ. des
Prog.,t. VIII., p. 238,) M.  Randolphe, (Encycl. des  Sc. Med., 1839,
p.  195,) and Bravais  (Soc. de Sante de Lyon, t. II., p. 97,) have
also  met  with  cases  where  its orifice terminated in  the  excre-
tory duct of the urine.  In patients mentioned . by M. Fristo, (com-
municated by the  author,  1838,) it opened in  the  loins  in  one case,
and upon the dorsum of the  penis in  another.   M. Palmer men-
tions a  case of imperforate rectum where the intestine  terminated
on a line with the sacro-vertebral  angle, after having made several
zigzag turns, being the case of a female infant who lived four days,
and in  whom the  operation for imperforate  anus was  performed
without success.  In another infant the rectum terminated in a cul
de sac, and by a filament at the upper part of the sacro-vertebral an-
gle, (Lieutaud,  Bull, de la Soc Anat.,  May, 1839,  p.  86.)  In the
case of M. Olinet, (Journ.  Univ. des Sci. Aled., Feb. 1820,) the anus
was prolonged by means of a canal to as far as within two lines of
the vulva, where it opened.  In the case of Littre,  its exit was at the
hypogastrium; in those of Mery and Hartmann, at the  umbilicus ;
in those of Schurig, Bonne, Desgranges and M. Dieffenbach, it was
at a point on the vagina; in the  two  cases quoted by M. Champion
and M. Ribes from  Cnoeffelius, La Faye and M. Lacoste, it perforated
through the sacrum ; in the case of M. De la Salle, at  the  membra-
nous portion of the urethra; and  in that of Desault and a number
of others, in the bladder.   The cases of artificial anus perforating
the sacrum  have,  moreover, been met with  in several instances,
whether, as in  the  cases of Cnoeffelius (Eph. contre nature, Dec.
1, an. 4, 5, Obs. 65, 1773-4) and M.  Fristo, there  was no accompa-
nying opening  at the  natural place,  or whether,  as in the patients
of La Faye, (Princ de Chir.. &c,)  M. Lacoste, (Bull, de la Soc.
Med. d'Emul, Oct. 1822, p. 417) and M. Ricord,  (Rev. Aled., 1834,
t. III., p. 473,) there was only a simple hernia of the rectum, which
had or had not ulcerated  through the sacrum.  The recto-vaginal,
recto-vulvar, and all  other kinds of external  anus  from defect  of
conformation, are disgusting infirmities, but do not necessarily cause
death.   On  the contrary, the infant dies  by  necessity  in a short
space of time when the intestine  is entirely deprived of an exit, or
when it opens into an organ which does not communicate with the exte-
rior.  In both cases art has but two kinds of remedies to make trial of:
1.  To re-establish the anus in its natural position ; and 2. To make an
artificial one on some other point of the abdominal cavity. 
IMPERFORATION.
759
              §  I.—To re-establish the Natural Anus.

   A.  When the anus  is closed only by the skin, or by a layer which
 does not however possess  but  a few  lines of thickness, its resto-
 ration is never a very difficult  operation.  A projection  and a blu-
 ish  spot generally point out  its  seat,  and the  obscure  fluctuation
 which is sometimes perceived there by the finger enables us to act
 without any apprehension.   In  place of circumscribing it by a cir-
 cular incision, as recommended by Levret, the surgeon should plunge
 the  point of a straight bistoury or trochar into the centre of the spot,
 in the  direction of the  rectum, and down to the seat of the  me-
 conium.   Having enlarged  the  puncture in the antero-posterior
 direction and transversely,  he excises fhe four flaps;  he then places
 in it a tent of lint or linen, or in fine, a suppository, in order to pre-
 vent it from closing up again, and afterwards continues to dress it in
 this manner with dilating bodies until it has perfectly cicatrized.  A
 certain number of cures have been obtained in this manner, and are
 such as  would justify no delay  under such circumstances.
   B. We  should also  act in this  manner in those cases where, though
 the  anus  may  exist,  the  intestine  has been  closed  up  by a sep-
 tum at some  distance above.   Only that  it would be advisable in
 such cases  to surround the  bistoury with a linen bandage, unless we
 should prefer the trochar  recommended by J. L. Petit, or the pha-
 ryngotome, advised by  M. Martin.   In cases of this  kind the exci-
 sion of the angles of the crucial opening is no longer possible. The
 operation for this deformity was successful in the case of Pistor in
 1764, as  it had been before, and as it has since been in the hands of
 Moncelot, Loyseau, Demarque,  Underwood, and M. Ouvrard.  The
 instances of cure related by MM. Phelys, (Bull, de la Fac de Mid.,
 4th year, p. 102,) Laracine, (Bull, de la  Soc Med. d'Emul, 1824,)
 Sandras, Duparcque, Forget, (Rev. Med., 1835, t. II.,  p. 284,) Jodin,
 (Journ.  Hebd. Univ.,  t.  111., p.  413,) Salmon, (Gaz.  Med., 1838, p.
 456,) and Bouyer, (Bull, de  VAcad. Roy. de Med., t. II., p. 818,) also
 probably belong to this  class.   The  infant, however, that was ope-
 rated upon by M. Goyrand, (Journ. Hebd., 1834, t. III., p. 245,) died
 in consequence at the  expiration of twelve days.  MM. Wolff,  and
 C. Hutchinson, (S. Cooper, p. 209—S. Cooper, Diet., p. 208,) have
 both succeeded  once in new-born infants, who had an imperforate
 anus of  this description.  The  deformity  in one of  them was  not
 noticed until the 12th day.  In a case of similar anus, M.  Miller,
 (S. Cooper, Diet, p. 210, edit. 1838,) was obliged to repeat the ope-
 ration eleven times before he succeeded.
  C. An anus opening at the fourchette in a little girl, as in the case
 published by  M. Brachet, could be  readily  restored to its natural
 situation.  A straight bistoury guided by a grooved sound through
 the fistula into the intestine, and directed from before backwards,
or from  the perineum to the coccyx, or from  above  downwards,
 would  divide  all  the  tissues  which  had caused the  deviation.   A
canula fixed in the rectum  near the  posterior angle  of the wound,
would enable the solution of continuity  in front to cicatrize, and the
matters to reacquire their normal direction.   The same operation
was  recommended by Vicq d'Azyr  in cases of vaginal anus.  M. 
760
NEW ELEMENTS OF OPERATIVE  SURGERY.
 Martin recommends, that after having incised the entire septum from
 above downwards, and from before backwards, as  in the preceding
 case; and after having placed  the  canula in  such manner that  it
 may go a little beyond the  fistula above, that we should reunite the
 wound on its anterior surface by means  of the suture.   This last
 stage  of the operation, which is undoubtedly the most difficult, does
 not appear to me  to  be necessary.  If the derivative tube  is pro-
 perly  adjusted, the reunion  of the divided tissues in  front will be
 effected without the intermediation of  the threads.  There would also
 be a mode of avoiding this, and  of accomplishing the same result
 with less inconvenience ; this would  be to  ascertain, by means of an
 instrument  curved  backwards in the form of a  blunt hook, and
 brought from above downwards,  through  the  fistula, to what point
 the intestinal cul  de sac descends,  and then to penetrate into the
 rectum by  a puncture from the  skin towards the pelvis, without
 dividing the recto-vaginal septum.
   D. In infants  of the male sex we  have  not  the  same resources.
 As the meconium  only  comes out at the  time o?  discharging the
 urine, it does not, though it shows that the anus is entero-vesical, indi-
 cate either the direction or precise  seat  of the termination of the
 rectum.  If it escapes from it at every  moment  or  at intervals,
 and without  any mixture of urine, the  opening is  probably in the
 urethra.   Although we cannot always ascertain whether it is  at  a
 short distance from the glans penis, as M. Monod has  seen it, (Bibl.
 Med., 1829, t. II., p. 447,) or deeper in, and near the  perineum, as
 it is found to be  in most cases, we have nevertheless good grounds
 to anticipate some success in such cases, by a methodical perforation
 at the usual place of the  anus.  In the first case, as in  those  where
 nothing outside can enable us to understand the interior condition of
 the parts, the operation, as it would, so to speak, be  made at hazard,
 would necessarily be attended with less chances of success.  To in-
 cise the perineum and neck  of the bladder in  the  same way as in
 lithotomy, in order to create a  large common issue  both for the
 urine and  stercoral matters, in those cases in which the  intestine
terminates in the bladder, would be a remedy, if not as dangerous,
at least as revolting as  the disease itself.  The infant in whom Ca-
venne de Laon deemed it advisable to make  trial of this operation,
died in the course of the evening, and M. Martin of Lyon who has
recommended it, had doubtless not  reflected that  his  process, by
leaving the recto-vesical anus in  its  congenital state of constriction,
 could not have been attended even with the advantage of  prolong-
ing the life of the child.  If M.  Ferguson, (Arch. Gen.  de  Med.,
t. XXVIII., p. 563,) has succeeded by operating in  this manner, the
 cases of Zacutus-Luzitanus, and of M. Willaume, are much less cal-
 culated to inspire confidence.

                             §11.

   The method of seeking for the intestine through the tissues which
 separate it from the cutaneous surface, is the only one up to the pre-
 sent time which  presents any prospect of success in obscure cases.
 The infant is to be held, with its limbs apart and flexed, upon the 
IMPERFORATION.                      761
 knees of an assistant, or upon a table properly prepared.   The  sur-
 geon placed  in front explores the perineal or inter-gluteal  depression
 if any exists; if he encounters no indication of anus or intestine, he
 endeavors to recognize the point of the coccyx and places the centre
 of his incision at about ten lines in front of. this bone, and then divides
 first the skin to  the extent of from ten to fifteen lines, and afterwards
 in succession the different layers which present themselves, until he
 comes down to the depth of an inch or two, that is to  say, down
 to the intestinal cul de  sac, should  any  present, or until  he  has
 lost  all hope of finding it.   The  left forefinger, which  constantly
 serves as  a guide  to the instrument, of itself applied from  time to
 time  to the bottom of the wound, would enable us to perceive* the
 projection  and fluctuation of the distended organ, and to ascertain in
 what direction it would be advisable to carry the point of the bistoury
 or trochar.  In  commencing, this dissection should be nearly in the
 axis of the body, that is to say, almost perpendicularly ; afterwards
 we should incline it by degrees towards the sacrum, in order not to
 touch the bladder,  and that we  might follow the usual track of the
 rectum.  The trochar in this respect is less certain than the bistoury.
 As the bladder in some degree fills up the  pelvis when the intestine
 is wanting, it will  almost inevitably  perforate it.   Moreover, it too
 readily escapes  into the  midst of the soft parts, to allow us here, to
 place  any great confidence  in it.  Puncture, in whatever way we
 should employ it, could not, without danger, be substituted  for dissec-
 tion, unless the sac, filled with its matters, was recognizable either to
 the finger or  eye, or upon the skin, or at the bottom of the  wound.
 Having once entered into the rectum we enlarge the incision with cau-
 tion in different directions, and especially in that where there appears
 to be the greatest room.   We then introduce into it a tent  of linen or
 lint,  or even a  canula, which terminates the operation.  We have
 nothing more to do than to keep open  the new anus, to give  it a
 sufficient degree of breadth, and to prevent its coarctation  or obliter-
 ation.   To incise  layer  by layer the tissues,  sphincter, levator  ani,
 &c, as M. N.  Roux has done, (Arch. Gen. de Med., 2d  ser., t. V.,
 p. 475,) is  neither better nor worse than the ordinary method.   To
 apply to the  anus in  these cases, what M. Dieffenbach has done for
 the lips, that is to say, to  detach the extremity of the rectum in order
 to bring down its mucous membrane and  sew it on the skin, would
 at the same time be attended with great danger and but little efficacy,
 and in most  cases  would be impossible.   M. Amussat, (Gaz. Med.,
 1835,  p. 753—Arch. Gen. de Mid., 2d  ser., t. II., p. 237,) who  has
 done this in one instance, does not say whether his patient remained,
 cured.  This operation, which we have frequent occasions of prac-
tising, is rarely followed by a complete cure.   Roonhuysen, F. de
 Hilden, (Bonet,  Corps deMid., p. 438,) and De La Motte,  who have
 been  most successful with it, allow that  most of their patients  ulti-
mately died at the  expiration of a few months, or one or two years,
 B. Bell, who has obtained some successes from it, asserts  positively
that it is almost impossible to prevent the new opening from  closin»
up again.   The  infant operated upon by  M. Jodin soon succumbed,
I have performed the operation on six patients.  Four died:  two
after  a manifest improvement;  the third  at  the expiration of  six
  vol. in.                       96 
762
NEW ELEMENTS OF OPERATIVE  SURGERY.
  weeks, from neglecting the precaution of keeping in the canula ;  and
  the  fourth from  my not being able to find  the  rectum, which was
  continuous, by means  of a filament, with the body  of the  bladder.
  The two others were cured, one at La Charite in  1837, and the other
  in the practice of M.  Layraud in 1838.  Failures in  cases  of  this
  kind have nothingyn them  to surprise us.  If the cure obtained by
  Wagler, after having in vain  incised  the perineum, and afterwards
  plunged, on the following day, a lancet into the rectum, which he
  thought  he  could distinguish  at the bottom of the wound, remained
  permanent and without any obstruction, this was owing doubtless to
  his not having been obliged to penetrate very deep, and to the intes-
  tine not having been very distant from the sphincter.   I would make
  the same remark  in regard to the little girl  operated  upon by  the
  surgeon referred to by  M. C.  L. Lepine, and  who died three vears
  subsequently of an  entirely different disease,  and  also  in regard to
  the more fortunate case related by M. Miller, (Arch. Gen. de Alid.,
  t. XIX., pp. 591, 595.)   The cause of this failure  is but too readily
  explained:  the lost portion of the intestine can never be re-estab-
  lished but in a very imperfect manner.   It is a fistula which we sub-
 stitute in place of the natural  tube.  The species of mucous  surface
 which ultimately becomes developed, can but very feebly represent
 the tunics of the anus.  Though the system be incapable of entirely
 closing up stercoral fistulas, it has a constant tendency to diminish
 them, so  that they soon become nothing more than mere ducts  for
 the passage of fluid matters.   The  absence of the sphincter espe-
 cially, is  a fatal bar to success.   When this is the  case, it would
 be extremely probable that the anus, which  had been artificially re-
 established, would  be one of  the most difficult to keep open.  It
 would be an error however therefore to conclude  with Dumas and
 some others, that an artificial anus on the side of the abdomen is always
 to be preferred.  This also is nothing more than a fistula devoid of a
 sphincter, and in all cases where  it  could  be located  in the peri-
 neum it certainly would be attended with still  less  unpleasant conse-
 quences.  Among the successful cases above mentioned, we may
 moreover add also some others, that of ML. Fristo, for example, (com-
 municated by the author, 1838,) though he was obliged  to penetrate
 to the depth of three and a half inches.

              § III.—To establish an Artificial Anus.

  A.  Littre is the  first person  who, in cases  of imperforate rectum,
 suggested the proposition, viz., in 1720, to construct an artificial anus
 in the iliac region, at the expence of the sigmoid flexure of the co-
 o;-;;  xCfn scarcely understand  how Dumas, (Journ. de Med.  de
 Sedillot,) who, after Toutain, (Journ. de Med., 1786, t. LXVL, p. 90,)
 suggested the same process in 1797, should have given himself out  as
 the inventor of it.  A. Dubois had  already, in  1783, performed it on
 an infant  who died  on  the tenth day.  Duret (Bull, de la Fac de
Mid., 3d year, p. 112) also had recourse to it with  entire success on
the 18th October, 1793,  while M. Pilhore of Rouen was  no less for-
tunate.  But the infant operated upon by Desault,  in 1794, survived
only four days.  The case of supra-pubic abnormal anus mentioned 
IMPERFORATION.                      763
by Voisin of Versailles, also encouraged the anticipations which had
been entertained from the results  obtained by Duret and M. Pilhore,
inasmuch as the infant was enabled to live by discharging his stools
through  this opening.   Since that epoch, it is true, those hopes have
been  deceived in many cases.   M. Ouvrard of Angers, (Lancette
Franc, t. II., p. 99,) lost his patient in 1820, as suddenly as Desault
did.   M. Roux was not more  fortunate in 1831, in a similar case;
and the same was the result in the patient of M. Monod, (Bibl. Med.,
1829, t. II., p. 447.)  Which after all is the operation which  would
never deceive the expectation of the surgeon?   M. Serrand, (These,
Montpelier, 1814; Bull, de la  Soc. Anat., May,  1839,  p. 90,) who
saw the  patient operated upon  by Duret enjoying good health at the
age of 21, states that he performed a similar  operation successfully
upon  a  little  girl in 1813.  The little  patient being  laid  upon its
back with its thighs extended, is to be held by one or two assistants.
The operator being commodiously situated,  makes a  little  above
Poupart's ligament, between the antero-superior spinous process of
the ilium and the  pubis, an incision of  about  two inches in extent,
then divides layer by layer the skin, fascia superficialis, aponeurosis
of the obliquus externus, the lower fibres of the obliquus internus, the
fascia transversalis, and the  peritoneum, which opening he after-
wards enlarges by using a grooved sound to  conduct  the bistoury.
The intestine, which is distended and of a livid or greenish color,
spontaneously presents itself behind the wound,  and is recognized
moreover by the  aspect of its external envelope and by the arrange-
ment of its fibres.  We now proceed to seize it and bring it to  the
outside by  the forefinger acting in the manner  of a hook, or by using
the thumb in connection with it.  A noose of thread which is imme-
diately passed through the mesentery, prevents it  from re-entering.
We open into it in the  direction of the wound  of the belly;  the mat-
ters now escape, and it becomes emptied.  We place a tent or meche
in the division, if we are fearful of its closing  up too speedily.  Ad-
hesions soon become established between the surface of the colon
and the  lips of the wound in the belly.   We withdraw the mesen-
teric thread from the third to the fifth day, and the new anus, which
is then definitively formed, requires no  further attentions than those
demanded by any artificial anus whatever.
  B.  The process of Callisen, which  consists  in  penetrating at  the
side in order to reach the left lumbar  colon between the two layers
of its mesenteric duplicature, and without opening into the  perito-
neum,  has never been  put in practice  on a  living person.   I  am
wrong; M. Roux has once made trial of it, and the little patient died
two hours after.  It is  not worthy of being rescued from the oblivion
to which the moderns have consigned it.   Incomparably more diffi-
cult, and not less dangerous than  the  preceding, it would  be also
more  inconvenient.  I  am informed however that it has just been
performed  by a surgeon of Paris upon a woman affected with an
organic  contraction  of the intestine,  and that the patient is doing
well, (10th June, 1839.)
  C. Process of M. Martin.—Nor has the process  imputed by M.
Paris to  A. Dubois, and which served as  a text to M. L. A. Martin
in his thesis, viz., that of conducting through the iliac opening of the 
 ij-04          NEW ELEMENTS OF OPERATIVE SURGERY.

 intestine, according to the process of Littre, an exploring instrument
 from above downwards, so as to ascertain if it would not be possible
 ♦o  re-establish the natural anus by perforating the perineum, been
 up to the present time attempted, except upon  the  dead body.  We
 should be wrong however in proscribing or rejecting it  in an abso-
 lute manner.  If by chance we had been deceived, and the rectum
 descended sufficiently low down to be made continuous as far as the
 skin, without being attended  with too much difficulty, we  should be
 in a much more favorable condition to perform the operation.  A
 flexible  sound, or one that was  properly curved, would in the  first
 place enable us to ascertain in what condition the parts were  situ-
 ated.  I would not however  recommend  either the large  flexible
 canula  nor the enormous trochar  of M. Martin, for the purpose of
 transfixing the parts in this manner from the interior to the exterior.
 It would be better, in my opinion, to look for the point of the explo-
 rator, by penetrating through the perineum, or if it should be found
 possible to  introduce  through the  pelvis  a sonde-a-dard, the arrow
 of which pushed as far as to the outside of and in the direction of the
 anus, would become the conductor of the bistoury  during  the re-
 mainder of the  operation. However,  as it would be somewhat im-
 prudent to multiply in this manner  the  incisions at the same sitting,
 and that there would  be always time sufficient to do this afterwards,
 we might wait before we did  so until  the  health of the infant had
 been restored to its natural state, and  when we could thus  choose
 an epoch apparently more suitable.
   D. If the safety of the method of Littre had  been sufficiently de-
. monstrated by experience, new-born infants would not have been the
 only persons to derive some advantage from it. It might equally be ap-
 plied to the sufficiently numerous cases of intestinal obliteration which
 show themselves after birth.   Every coarctation  of  this kind being
 fatal, we cannot see what objection there would be to the establish-
 ment of an artificial anus.  The difficult point evidently would be to
 ascertain with certainty, first, that  the obliteration exists, and then
 that it has its  seat in the rectum, or  in the lower portion  of the
 iliac sigmoid flexure of the colon, or, at least, in the large intestine, so
 that in placing the anus in  the right iliac fossa, it  might be placed
 above the disease.  We nevertheless still succeed in doing so in quite
 a considerable number of cases.  Braillet  had no doubt of it in the
 patient whose  history he has given.  Nor was M. Martin  Solon de-
 ceived in the fact cited by M. Paris.  This result was  scarcely less
 evident during the disease of Talma.   I could make the same remark
 of a woman who died  in 1825 at the clinique externe of the school,
 and whose dead body I examined.   This process, moreover, would
 require no other modification  than this ; that in place of always being
 performed on the left, it might become indispensable  to direct the
 instrument upon the right iliac fossa, if the coarctation were situated
 in the transverse or ascending colon.   After all, this operation  does
 not exist only in theory ;  I have already said this  (see this vol., supra,)
 in speaking of gastrotomy, and of practitioners who had had the bold-
 ness to perform  it on living man, and that M. Martland, (Bull, de Fer.
 t. VIII., p. 204—t. XIV., p, 255,) who was the first to make trial oif
 it, viz.,  in 1814, was so fortunate as to  cure his patient. 
CONTRACTIONS.                     1&>
                   Article II.—Contractions.

   Coarctations situated in the rectum, whether congenital or ac-
 quired,  and  which are  not cancerous  but  purely  organic, are
 susceptible  of the  same operations  as  those of the urethra.   The
 species of fold or valvular border which is  observed in the interior
 of the rectum, a little above  the  sphincter, which no person had
 clearly pointed out before the time of M. Houston, and which  repe-
 sents a kind of pylorus, explains their great frequency at the  upper
 part of the anus.  Higher up they depend almost always upon ulcer-
 ations or degenerescences  that are difficult to  reach, or upon that
' species of fleshy ring described under the name of an upper sphincter
 by M. Nelaton, (see my Anatomie  Chirurgicale, 3d edit., Paris,  1837,
 t. I., introd.,)  and, consequently, they yield with less  facility than the
 first to surgical remedies.

                         § I.—Dilatation.

   The employment of dilatation in contractions  of the lower portion
 of the rectum, which was so much  eulogized by Desault, and  since
 the time of that author by the majority  of surgeons, merits, in fact, a
 part of the encomiums which have been bestowed upon it.  All those
 indurations which  are the consequence of chronic phlegmasias, and
 which occupy only the mucous membrane or subjacent cellular tissue,
 and also even certain lardaceous degenerescences, admit of the trial
 of this process.   Dilatation acts here like compression in the external
 engorgements, and  upon the same principles.   The excentric  pres-
 sure which  it  makes, compels the effused matters which have become
 solidified in the midst of the natural organic tissues, to re-enter into
 the general circulation, restores the intestine gradually to its original
 thickness by  enlarging  it, and in many cases breaks up the morbid
 process by destroying its germ.  But this result is not obtained with
 equal  facility  upon all the points of the rectum, nor in all the differ-
 ent kinds of coarctation.  If the  disease  consists  of prominences
 which exist to a greater extent external to, than in the interior of the
 canal, or if it occupies a point which is too unfavorably situated for
 the pressure to be made with accuracy, or if the apparatus is  badly
 applied, the dilatation, in general, will do more  harm than good.   It
 is executed by means of meches of lint spread with cerate or medi-
 cated  pomade, which are daily renewed and gradually increased  in
 size.   These  meches, which may be replaced by any other pliant or
 flexible cylindrical body if necessary, are applicable to affections of
 the anus, properly  so called, and those  of the upper portions of the
 rectum.  Between the sphincter and the concavity of the sacrum it
 is almost always necessary to proceed  in another manner.  A small
 linen sac, which is  introduced empty in the manner of a purse which
 is reversed, and which is filled with lint in order to make compres-
 sion from above downwards  as well as upon the contour while we
 are withdrawing it, is then most suitable and ought to be preferred
 to bladders distended with air, water or liquids of any other description.
   These two  methods nevertheless  have an inconvenience which is
 common to both  of them, that of arresting the course of the matters 
766          NEW ELEMENTS OF  OPERATIVE SURGERY.
and thereby occasioning a considerable  degree of irritation in  the
greater number of patients.  It would be advisable, therefore, to imi-
tate M. Bermond of Bordeaux, and to substitute the apparatus recom-
mended by this physician  in place of the meches or purses which I
have just mentioned.  This apparatus consists of two canulas which
are about six inches long,  one internal, smooth and terminated above
in a cul de sac, the other external, open at its two extremities, and hav-
ing on its outside at different intervals, circular grooves, in order to
attach a chemise Jo it.   They are introduced, sheathed in this man-
ner, into the organ.   By means of long forceps, we glide lint between
them and their linen envelope, in such manner as to  push back this
latter in  the  shape of an annular border as  far as to the top of  the
instrument, and  in such  manner also as to make a greater degree of
compression in one direction and less in another, according as it may
be found to be necessary.   The whole apparatus is fastened outside.
When the patient has need of going to stool, we withdraw the inter-
nal canula and without deranging the other, which may have as much
as six lines  in diameter.  The tail-piece, formed by  the chemise
above, almost of "necessity encourages the matters to enter into this
part, which  matters  may  be rendered more  fluid and diluted, if  ne-
cessary, by means of injections or  lavements.   We afterwards re-
place the central canula,  which locks by a lateral  eperon  into  a
notch which  is on  the outside canula near its free extremity.  The
fusiform  suppositories contrived by M.  Fardeau, (Journ. Hebdom.,
1835, t. IV.,  p.  116,) whether  they are hollow,  solid, or ovoid,  or
terminated below in a  funnel, or  of silver,  ebony,  or gum-elastic,
or those of softened ivory,  which I prefer, are still more commodious.
The meches, small sacs of linen, bladders, and  double canula of M.
Bermond, are no longer applicable, when the finger cannot reach up
to the diseased point.  M. Costallat (Gaz. Med., 1834, p. 11) has there-
fore contrived, for these particular  cases, a  small  apparatus,  which
may be introduced to more than a foot in depth,  and which in other
circumstances also should not be neglected.   I have  already spoken
of it in treating of contractions of the urethra. This is also a chem-
ise, but in the form of a cundum. which is preceded by a long blunt-
pointed probe and conducted by a gum-elastic catheter, after which it
is transformed into a meche by means of portions  of cotton, which are
pushed up into its interior by a forked stilette. Its inventor informed
me that he had used it with advantage on a number of persons, among
others upon a female patient whom several  distinguished surgeons
had  supposed to be incurable.  But this patient afterwards came to
La Pitie, where  I had an  opportunity of examining  her. and found
the coarctation of the intestine had returned  to as great an extent as
at first.   It is unfortunate  that it is  so much complicated as to pre-
vent its coming into general use, for the  idea upon which it is based
is ingenious, and it would  be  desirable to have  it simplified in such
manner as to enable every person to make use of it.

                        § II.—Incision.

  Before dilatation had  been proposed,  and  also  even  since it has
been employed to a very considerable extent, incision of the coarcta- 
CONTRACTIONS.
767
tions of the rectum was had recourse to either as an auxiliary means
or  as  the  principal remedy.  Wisemann performed  this operation
three times on the same patient, and Ford had the good  fortune to
effect a cure in his without a return of the disease.   The same re-
mark applies to M. Copeland, (Dublin Hosp. Rep., p. 150.) who had,
moreover,  to excise various tumors upon the intestine.  The opera-
tion in other respects is attended with but little difficulty, unless we
have to go very deep.  The blunt-pointed bistoury, conducted flat-
wise upon the  forefinger,  and  then introduced into the  contracted
circle, is the only instrument we require. Its cutting edge being turned
towards the walls of the intestine, divides them upon one. or on sev-
eral points, and in such manner  as not to go deeper than the thickness
of their tissue.   A large sized  meche or fusiform dilator is then in-
troduced as far as to above  the wound, after which we proceed  in
the same manner as in simple dilatation.  M. Begin (Elem. de Chir.,
2d edit., 1.1., p. 327) has like myself succeeded by adopting this pro-
cess.   The kiotome or bridle-cutter of Desault  would be applicable
to cases of this kind, if any particular instrument were deemed ne-
cessary.  We might also use the pharyngotome, as M. Duplat has
done  in  one instance with success.  As soon as the finger can no
longer accompany the bistoury, the incision is attended with too much
danger to  be thought of for a moment.   In  conclusion, the annular
contractions  or those in form of a  bridle, or that are semilunar, are
the only ones that admit of a trial of this process; and it is only, in
fact, for the purpose of preparing or favoring the dilating means to
be made use of, that it can be seriously recommended.

                      § III.—Cauterization.

  It is a matter of surprise that caustics  have  not been applied to
contractions of the rectum  in the same way as to those of the ure-
thra.   There is  every reason to believe, however, that they would
produce the same effects ; and that the nitrate of silver used topically,
or as an escharotic would add greatly to the success of dilatation, by
destroying the phlegmasic  germ upon the mucous coat of the  intes-
tine, in the same manner as it  so frequently does in  the  excretory
canal of the urine.  But I am hardly aware that it has yet been used
in such cases, and therefore cannot, without some other  foundation
than theory, or the analogies derived from imperfect trials made by
myself, enter into farther details on this subject.  I find, however, an
instance of this kind which is quite conclusive, in  the thesis support-
ed by  M. Duplat.  (See on  the subject of contractions of the rectum,  »
the thesis  of M.  James, Paris,  1838; a memoir  of M. Maslieurat,
Gaz. Mid., 1839 ; and the  work of M. Syme, on diseases of the rec-
tum, 1838.)
  [Polypi  of the rectum, when  found, as they not unfrequently are,
in children, appear under certain modifications distinct from those in
adults.  M. Gigon of Angouleme, (see Hervez de Chegoin in Arch.
Gin. de Med., &c, Paris, 4e ser., t.  I., pp. 489, 490,) states that they
are, according to his researches, destitute of an epithelium, of moder-
ate size, and have  quite a slender pedicle.  They  are not apparently
an exciting cause of prolapsus of the gut, so common in childhood 
768
NEW ELEMENTS OF OPERATIVE  SURGERY.
inasmuch as this last infirmity is usually found in debilitated  consti-
tutions, while the polypi are met with often in robust children.  M. Gi-
gon divides these polypi into three classes : mucous, vegetative, and
fleshy.   They are also provided with vessels, and though  M. Gigon
has rarely found any unpleasant hemorrhage from their excision, M.
Roux considers that  this may occur, and  should  be guarded against
by a precautionary ligature.  M.  Roux, in  applying  a double liga-
ture to the pedicle of a polypus in a lady, had to observe much cau-
tion, for fear of passing the'needle through the arteries which he dis-
tinctly felt pulsating in this connecting part.
  Tincture of iodine in its strong and undiluted state, injected into
the track of an anal fistula, completely closed it up and effected a
radical cure of the disease, in a case in which it was made trial of by
Dr. Charles Clay, (London Aledico-Chirurgical  Review,  Oct., 1843.)
The careful introduction of a  meche into  the intestine  to a point  be-
yond the intestinal opening, enabled  him to ascertain by its  color that
the iodine had passed completely through the abnormal canal.  T.]
                        CHAPTER II.

         BODIES TO BE EXTRACTED FROM THE RECTUM.

           Article I.—Foreign  Bodies in the  Anus.

  The nature, form, and size of foreign bodies that have become ar-
rested or been introduced in the lower part of the rectum, present
so many different varieties that no systematized operation  or fixed
process can be applicable to them, so that  their  extraction  requires,
so to speak, to be modified for  each particular case.

                              §1.

  The fingers and thumb, the dressing or lithotomy forceps, or the
entire hand when it can be introduced, are the first means  that sug-
gest themselves.   The  hand of an expert child,  as was done  in the
patient who had stuck  a cologne-water bottle above  his sphincter
as mentioned by Nollet, or the  hand of an intelligent midwife ought
to have the preference, if the  hand of the surgeon  should be too
large.   A man had introduced  a vial into his rectum, and M Cuma-
no, (Gaz. Med., 1838, p. 793,)  extracted it by means  of Boer's for-
ceps.  A drill orturrell  would be a valuable acquisition, if the foreign
body in question was a fragment  of wood or vegetable, or animal
substance, and solid and not flexible, as is proved by the cases  re-
lated  by Saucerotte and M. Bruchman.  A pig's tail introduced  by
its base, and the  hair of which  previously  shorn off, would rub
against  the intestine,  should  be treated as Marchettis suggested
(Bonet, Corps de Med., t. III., p. 277,) in that  courtesan  who was
a victim to the students of Gottingen: by means of a thread tied to 
FOREIGN BODIES IN THE ANUS.
769
 its lower extremity, he succeeded  in gliding  over the foreign body
 from below upwards a reed tube, which thus  quickly isolated it from
 the walls of the intestine, by forming a sheath to it, and immediately
 allowed of its extraction, without any difficulty.

                              §11.

   A patient had thrust into his rectum a pot  for preserves, with  its
 open extremity first.   A violent irritation was the consequence of this
 singular manoeuvre, and the intestine soon became inverted from above
 downwards into the pot  in the form of a red  tumor, which filled  up
 its cavity.   Desault was not enabled to extract it until he had applied
 two strong forceps successively on the two opposite points of one  of
 its diameters.   In place of two we might even employ four forceps,
 either in order to draw with greater force, if it were necessary, or to
 dilate at once on a greater  number of points of  the anal contour.
 A  large ring or ferule, or metallic goblet would  doubtless be found
 to  yield to this  means.   If it were a glass or crystal or porcelain,
 or any fragile body whatever, the forceps would enable us at the
 same  time  to break it if it should appear impossible to  remove it
 entire.  M. Manunta (Gaz.  Aled., 1838,  p.  185)  made use of a
 lithotritor to break  a coffee-cup which a young student had intro-
 duced into  his rectum.  A narrow saw, protected by a gorget and
 the forefinger, might  be  used in  the case of a  fragment of wood,
 horn or ivory, which had become fixed transversely on each side  of
 the wall of the  rectum; while foreign bodies of steel, iron or silver
 might in some instances require the aid of cutting tenacula or cutting
 pliers  themselves.
                             § III.

   Biliary calculi, and hairy balls, (egagropiles,) which are sometimes
 found  in the intestines of men as well as  in those of animals, should
 be  broken up by means of strong tenacula or  cut into fragments with
 long and strong scissors, should  the hooks, the hand, and turrell and
 drill not be found  sufficient.  Hardened fiscal matters, bullets, and
 stercoral stones, which in many persons are the source of accidents,
 the character  of which is so frequently misapprehended, also do not
 yield  in certain cases except by the use of blunt hooks or the finger,
 or wooden spoons of greater or less length, or the delicate hand of a
 child  or  woman.   M. Thiaudiere, (Bull, de Thirap., t. VIII., p. 29,)
 by introducing his entire hand into the intestine, was enabled to ex-
 tract from it an enormous wooden fork five inches  long.  The cases
 related by J. Warren, Van Swieten, Camper  and J. L. Petit, as well
 as  those by Guillemeau, Schurig,  Callisen, Vicq d'Azyr, and MM.
 Gibert and Ouvrard, show what we have to fear and what resources
 we have to  employ in such cases.

                             §  IV.

   Calculi, giving rise to constipation, have been extracted from the
rectum by Schmucker, by means  of the  forceps; and also  by the
ordinary forceps, after having broken them up, by Chambon and M.
  vol. in.                    97 
770          NEW ELEMENTS OF  OPERATIVE SURGERY.

Miller, (Arch. Gen. de Aled., t. XIX., p. 593.)  J. S. Buzzoni removed
from  it a coffee-cup by means of  a whalebone busk.  Plater (Bonet.
Corps de Mid., 2d part, obser. 31) says seriously, that a mole, intro-
duced alive into  the  rectum of a peasant, had become so strongly
attached to it that it could not  be extracted except by drawing upon
its tail after having killed it!

                              §  V.

  We do  not proceed to debridements and incisions, either of the
anus  or intestine, on  higher points of its walls,  until  after  having
satisfactorily  established  the insufficiency or  inutility  of these  va-
rious  means.   We then,  as in  the  preceding cases, have  recourse
to the jointed speculum, or to  the  simple speculum, having a slit of
two to three lines, which  divides its whole length on the free side, as
recommended by M.  Barthelemy, either for the purpose of dilating
the anus or favoring the action of the other instruments.  As to  the
incisions themselves  we  sometimes  make them  with  the  straight
bistoury protected by a  bandage,  sometimes with the straight or
curved  probe-pointed bistoury, directed or guided upon the finger,
and finally, sometimes with a strong pair of scissors.  In conclusion,
foreign  bodies in the  rectum are treated scarcely in any other man-
ner than  those  in the vagina.   M. Cazenave (Brochure  in 8vo.,
1837) was obliged, in  one case, to extract a broken  gourd from it.
A pestle, which could  not be withdrawn without difficulty by means
of the forceps, caused rectitis  and death in a patient of M. Dor,
(Gaz. Med., 1835, p. 139,) who  succeeded better in another case in
extracting a fork, the  teeth of which were directed downwards, and
who states that he removed a cologne-water bottle in a third patient
by means of Hunter's forceps.  To the above mentioned  resources
there  ought, I think, to be added  in both cases the employment of
lithotritic instruments, while we should recollect that# in the rectum
or vagina, the litholabe,  perforators  and stone-bre'akers  may be
managed with more facility and less danger than in  the bladder or
urethra.

             Article II.—Polypi of the  Rectum.

  Polypi of the  rectum, though not very rare, are nevertheless not
very  common.  At the height of 6 or 8 inches, it is almost impossible
to reach them, and consequently to ascertain their  existence.   While
they may  be  more easily reached in proportion as they are lower
down, they also yield  to the same methods as for those found in the
sexual organs in woman.  Their excision also is effected with too
much ease to allow any attempt  at arrachement  and cauterization.
The  ligature itself is scarcely ever adapted to them  in  any case.
Above  the sphincters  they are secured by means of a double erigne
or erigne forceps, which is  then handed to an assistant to hold.  If
the anus presents any difficulty, a jointed speculum is introduced into
it.  The surgeon then, provided with a long pair  of scissors  curved
flatwise, and protected by the left forefinger, divides its  pedicle.
Lower down the excision is made in the same manner  as for hemor-
rhoids,  which will be  mentioned presently; in both cases we  put our- 
HEMORRHOIDAL TUMORS.
771
 selves on our guard against hemorrhage, by the  means which will
 also be described farther on.  The excision of a small fungous, pedi-
 culated tumor from the anus, was followed by so copious and so sud-
 den a hemorrhage, that the patient, who was a young soldier, would
 have died if M. Serre (Compte Rendu, 1838,  p. 35) had not prompt-
 ly had recourse to tamponing of the rectum.  MM.  Manec (Journ.
 des  Conn. Med., January, 1839, p. 107) and Meric, in excising a fun-
 gous polypus from  the rectum, after  having ligatured its pedicle,
 found a copious hemorrhage ensue at the expiration  of twenty-four
 hours.  The patient was afterwards restored  without any accidents.

              Article  III.—Hemorrhoidal Tumors.

   Hemorrhoidal tumors, bourrelets  (collars), and tubercles, which
 M. Le Pelletier (Des Hemorrh., &c, These de Concour. Paris, 1834)
 has  examined under all their varieties  in his excellent  thesis, and
 which are sometimes concealed in the interior of  the anus, and visi-
 ble only when the  patient makes an effort at  stool, and which some-
 times protrude externally, are the source of a great number of incon-
 veniences and dangers as  soon as they have become  definitively
 established, in spite of the methodical and judicious employment of
 antiphlogistic, detergent, astringent, and escharotic topical means, to-
 gether with compression.  Cauterization with nitrate of silver, suc-
 ceeds only in the beginning, or only when they are yet very incon-
 siderable in  size.   The red-hot iron, which was so much extolled by
 the ancients, (Dujardin, Hist, de la Chir., p. 500,)  and which M. A.
 Severin was so vexed at being prevented from using in a patient of
 distinguished family, in consequence of the obstinacy of the cowardly
 physicians (Idches medecins) of this personage, would doubtless suc-
 ceed better and in  a  greater number of instances ; but those resour-
 ces which surgery at the present day possesses, and which are at the
 same time more certain and less repugnant, have  long since cast it
 into oblivion.
                             § I.

  At the present day the ligature itself, though of easy application,
 is generally laid aside in France, notwithstanding  the arguments ad-
 duced in its  favor by  M. Mayor, (Gaz. Aled., 1832, p. 24.)   The
 tumors that have no pedicle, or the simple bourrelets, do not admit
 of its employment, and  the  examples given by J. L. Petit show that
 in other cases it may give rise to the most serious accidents, such as
 violent pains, syncopes, convulsive movements, and inflammations of
 the intestine  and peritoneum, whether we afterwards wait for the
 spontaneous separation of the  morbid production, or whether, on the
 contrary, we excise it  immediately outside  the  thread, as had been
 already recommended  by Galen.  It is true however  that M. Brodie
 (Kleinert's Repert., March, 1836, p. 92) avers that he has employed
the ligature on hemorrhoids in 300 instances, and only lost a single
patient; I will add with M. Gibson, that my experience does not
allow me to coincide with the prejudices  of J. L.  Petit against this
remedy; but as the internal  hemorrhage attributed by M. A. Cooper
or M. Brodie to excision has rarely taken place  among us, it is very 
772          NEW ELEMENTS OF OPERATIVE SURGERY.

natural that we should not have the same  confidence in the ligature
to hemorrhoids that these practitioners  have.   Excision therefore at
the  present time is  almost the  only operation which ought to be
had  recourse to for these affections.

                             § II.

   Excision of hemorrhoids in itself is rarely attended with any great
degree of difficulty.  It can only in reality be serious in consequence
of the hemorrhage, or inflammation, or purulent infection which may
result from it; from whence it follows that the best process must be
that  which  incurs the least risk of these  accidents,  and  which  is
most certain to be exempt from them.
   A. Ordinary process.—The patient being laid upon the edge of
the bed, or a table properly prepared, with the  under thigh extended
and  the other flexed, so that the anus  may  be perfectly exposed, is to
be held by  several assistants.  The surgeon placed in front  of the
affected part, ought, according to Boyer, to seize with  a good pair of
dissecting forceps or an erigne, all the tumors in succession, proceed-
ing from  those which occupy the most depending point to those that
are highest up, and then detach them one after the other by means of
the bistoury or  a  strong  pair of scissors.   If they do not protrude
externally, an effort similar to that on going to stool compels them
to come out; but  as the pain caused by the removal of the first  tu-
mor  almost  always occasions a considerable retraction of the anus,
which draws back the others into the bottom of the rectum, it is im-
portant not  to excise any of them until they are all secured,  with a
like number of erignes or forceps, or by traversing or surrounding
each of them with a thread. . To dissect them in the manner of
cysts, in order to remove only the smallest portion  possible of their
mucous membrane or skin, as some authors  propose,  is altogether
superfluous.  It is a piece of advice moreover  which  is much easier
to give than to follow.
  1.  The loss of substance here has nothing in it alarming.  The
wounds cicatrize very well, and after the cure  the organ usually  re-
gains all its suppleness.  The dressing consists of the introduction of a
meche of some size  besmeared with cerate, inserted to  the depth of
several inches, and supported outside by coarse lint, compresses and a
T bandage.  M. PI. Portal, (Clin. Chir., &c, p.  147,) in extirpating
an erectile tumor  which had become implanted in the  anus and upon
the neighboring integuments, met with entire success, and his patient
was  restored in five weeks.
  II. Hemorrhage.—Should  we  apprehend ever  so  little loss  of
blood the dressing is  to be no longer as simple.  Boyer begins  by
introducing  to a considerable depth a long  tampon of lint nearly cyl-
indrical in  shape, and also  solid, and embraced by two strong liga-
tures, which are  crossed on its upper extremity, and knotted  and
firmly secured upon its lower extremity, and the extremities of which,
collected together in two pairs, remain pendant outside of the anus!
We  afterwards push  in below this a number of small balls of lint or
additional free tampons in such manner as to fill up  the end  of  the
rectum with them.  Fastening the  whole below by means of a large 
HEMORRHOIDAL tumors.
773
roll  of lint  placed between the buttocks, over the anal opening, the
surgeon then draws upon the two ligatures and  knots  them on this
roll with a sufficient degree of force, to make the  lint contained in the
intestine apply itself from above  downwards against  the  bleeding
surfaces, at  the same time that the tampon outside tends to push it
backwards,  from below upwards.  Finally, a large  plumasseau and
then compresses and the T bandage complete the dressing.  In this
manner it is  almost  impossible for  the blood to make  its escape,
while pure and simple tamponing would only have the  effect of pre-
venting its showing itself outside, while it would force the blood  to
effuse  itself into the intestine, and thus transform  the external into an
internal hemorrhage, which would be still more dangerous.   On the
other hand, if the compression is not accurately made, nor with suffi-
cient force, and if the apparatus of Boyer or J.  L. Petit  is not pro-
perly  prepared, or is badly  applied, the same accident  might  also
happen.  Moreover, it produces in  some cases acute suffering, an
almost irresistible  desire  to go to stool, a sense of weight  which it is
difficult to support, colics and even fever, and other symptoms, also,
which  render its  employment quite difficult.  Also it is frequently
indispensable that  an assistant should support it during the space of
some hours by means of his hand, and that we should enjoin upon
the patient  not to make any  effort,  but resist  with  all his moral
energy the desire  which he  may feel to expel  it, but  which rarely
fails to subside after the first few hours.   I have no necessity of add-
ing that we should remove all  the dressing in  order  to reapply it
better, if the swelling of the belly, syncopes, paleness, and contracted
pulse should indicate that the  blood  continues to flow;  nor  is it
required to say, that the  sensation  of a weight, or of a  foreign body,
which in certain cases is acutely felt even in  the absence  of every
kind of dressing, would be augmented instead of  being moderated by
any of those efforts of defecation which  the patient is forced to make
almost  in spite  of himself, and which he ought to abstain from at
every hazard.   If the chemise canula of M. Bermond had  been tested
under such circumstances I would willingly recommend it,  (see dila-
tation  of  the  anus, above.)  By means of this we might  change,
modify, and renew the dressing, and  augment or diminish  the com-
pression without taking off all the pieces, and  moreover,  satisfy our-
selves, by removing the  central canula, whether blood had or had
not become effused into  the intestine, and also could allow the mat-
ters to be  expelled  as often as the patient felt  a  desire  for it, and do
this during the space of several days if we judged it advisable.
  B.  The process  of Dupuytren rejects all precautions of this kind.
This surgeon  immediately applys a red-hot  iron on the  bottom of
each of the wounds he has made, wherever  he has reason to appre-
hend the slightest  hemorrhage.  He does nothing more  afterwards
than to place in the anus  a meche of but small size, which moreover
up is to be supported and kept as above described.  In proceeding in this
manner we  scarcely ever  find any accidents follow.   Nothing dis-
tends, irritates, makes traction  upon  or compresses either the intes-
tine, bladder or surrounding  parts.   The congestion which  is so
powerfully excited  by the ordinary dressing, exists but in the slightest
degree, and the hemorrhage consequently has very little tendency to
• 
774
NEW ELEMENTS OF OPERATIVE SURGERY.
 make its appearance.   In this respect the hot iron has the advantage
 of rendering the operation prompt, and is far from producing as much
 pain as the tamponing.  The inflammation, while it is less disposed
 to extend or to react at a remote distance, is not so liable to attack
 the veins which open themselves at the bottom of. the wound, nor is
 the development of those purulent collections caused by phlebitis or
 resorption, of which I  saw two patients  die at the hospital of the
 School of Medicine,  in 1824 and 1825, so much  to be  dreaded.   I
 do not know, in fact, if the cautery is in reality indispensable.   The
 arterial vessels which are divided are of  such little  importance, that
 the wounding of them  at first sight would not appear  to forebode
 much danger.  The  mouths of these vessels if left to  themselves
 would probably soon cease to give out blood, and I should not be sur-
 prised if the precautions recommended to prevent hemorrhage were,
 in quite a considerable number of cases, the cause of its occurrence.
 It appears to me, therefore,  that in a  majority of cases  they might
 be dispensed  with; and  that it is  from excess  of prudence  that
 they are recommended  in cases  where the loss of .blood at first is
 not abundant.  What, moreover, would prevent our having recourse
 to  them at  a later period, in cases where the hemorrhage should
 continue to go on to an alarming extent? Nothing is  more easy
 when  the wounds are  at the exterior.   If they were  deeper the
 patient, by making some efforts,  could soon expose them to the view
 of the operator, who  could  then cauterize them without difficulty.
 Finally, the tamponing would be a dernier resource, which we could
 always call to our  assistance in time.  Two patients in whom I pro-
 ceeded in this manner, in 1831, at La Pitie, had no reason to regret
 it.  The same  has been the  case with a great number of others
 whom I  have since operated upon.  I have, however, seen three
 patients succumb from  this operation, one  from  purulent  infiltration
 into the cellular tissue of the pelvis, the second from a phlebitis, and
 the third from an erysipelas caused by the  excision of a small simple
 pediculated tumor.                                           *
  C. Process of the Author.—With the   hope  of better avoiding
 hemorrhage, inflammation and purulent infection, I have proposed t6
 unite by first intention the wounds made by excision of hemorrhoidal
 tumors and bourrelets.   For this  purpose I  secure to the outside, and
 by means of an erigne, each tumor which is to be removed, and then
 traverse their root by a sufficient number  of threads.  Immediately
dividing the tissues in  front of them, by means of the bistoury or a
strong pair of scissors, I have nothing more to  do than to seize, in
succession all the threads, in order to knot them, and thus make the
same number of points  of simple suture.   Meches and  tamponing 
REDUCTION.
775
                         CHAPTER III.

             THE FALL OR PROLAPSUS OF THE ANUS.

   The descent of the fundament is  an accident which must  not be
 confounded with the protrusion through the anus,  in consequence of
 intussusception, of a more or less extensive portion of the intestine
 from a greater or less distance above.  The first is owing, as Friderici
 (Thises  de Haller, t. I., p. 8, French trans.,)  had already demon-
 strated, to a relaxation of the mucous coat of  the  rectum, while the
 other depends upon an  actual intestinal invagination.  This latter is
 less uncommon than is  supposed at the  present day.   M. Paillard
 (Rev. Aled., 1829, t. II., p. 398,) gives an instance of one, and M. Ne-
 laton has related others.   I have also seen some cases.   The perito-
 neum itself was  included  in the tumor in the woman dissected by
 M. A. Berard, (Soc. Anat., 6th March, 1828.)  The first alone, how-
 ever, requires the aid of special operative processes.   In infants, in
 whom it is very common, the  progress of age and the employment of
 appropriate topical applications  almost always succeed in curing it.
 In adult age it is  no longer the same.  Its obstinacy then frequently
 becomes the source of annoyance to practitioners, and of despair to
 the patient.  When  the tumor only  shows itself at each stool, and
 returns afterwards  with facility, it constitutes without doubt a very
 troublesome  infirmity, but one  which  does not  compromise life;
 whereas if the patient cannot  succeed in reducing it, it may be stran-
 gulated by the action of the sphincter, and become inflamed or gan-
 grened, §i- give rise to symptoms of the most alarming character.  In
 the patient of M. Sauveur (Ansiaux, Clin. Chir.  2d ed.,  p. 179,)  it
 was completely detached  by  means of mortification.

                    Article I.—Reduction.

  In  order to reduce this  tumor we proceed  in  the same manner
 as  in  cases  of eversion  of  the vagina  or womb.   After having
 cleansed  it with tepid water, and  then besmeared it with a mix-
 ture of oil and wine, the  patient being placed  upon  his back, with
 his  breech more  elevated  than the abdomen,  and all  the muscles
 relaxed, we envelope it with a fine line, in  order afterwards tt> make
 gentle compression upon  it from the circumference  to  the centre,
 and from below  upwards, by means of the palms of the  hands or
 the pulp of all the fingers, at the same time that the patient is pre-
 vented as much  as possible  from  making use  of  any effort.   We
 sometimes  succeed better by making pressure  on the centre of the
 mass, by means of several fingers united  together in the form of
 a cone, as if  for the purpose of entering  into  the anus, by  push-
 ing before us  the compress which covers the  tumor, and which is
 kept around it by the other  hand.  A  large sized meche, with or
 without a sac, is one of the means frequently employed to keep up
the  reduction.   The dilated bladder of Blegny,  (Peyrilhe, Hist, de la
 Chir., p. 38,)  Morgagni or Levret, (Art des Accouch., 3d edit., p. 38,)
as employed by M. Dieffenbach, (Arch. Gen. de Med., t. XVI., p. 287,) 
776
NEW ELEMENTS  OF OPERATIVE SURGERY.
 the ring of Bassius, the bandage of Cousin, the astringent suppository
 of Turner, a tampon of lint contained in a linen bag, or a  globe  or
 oval body of wood, ivory or gum-elastic, and in  women a pessary in
 the vagina; with astringent injections and hygienic means, are the re-
 medies to be made triafof for preventing the return of the prolapse
 of the gut.   M. Gervais (Journ. des Conn. Aled-Chir., 1839, p. 67,)
 having a case of extensive  prolapsus of the  rectum, which he was
 desirous of keeping up, made use successfully of a ball of cork, which
 he withdrew at the expiration of 30 hours.   Simple reduction equally
 succeeded with M. P. Dalmas,  (Journ. des Prog.,2d ser., 1.1., p. 266,)
 though the prolapsus was accompanied with serious accidents.  An-
 other remarkable example also of the same kind, has just been pub-
 lished, (Gaz.  des Hdpit., 1839.)

                  Article II.—Debridement.

   If the reduction had  become  absolutely impossible through the
 usual methods, or if it were  attended with danger, we  ought not  to
 hesitate to divide the sphincter on one or  both  sides of the  root of
 the prolapsus.  With the left hand we should push aside  the tumor,
 while with a straight bistoury in  the right hand,  we would incise
 the integuments and afterwards the muscular ring, that is to say, from
 within  outwards by commencing in the vicinity of the intestine. An
 operation of  this kind, performed by Delpech, (Mem. des Hop. du
 Midi,  1830,)  upon a young person  was  followed with  complete
 success.
                  Article  III.—Extirpation.

  When nothing can prevent the parts from protruding again, or when
 in spite of every effort they persist in not entering, they knew no
 other means to oppose to it  forty  years since, and many authors at
 the present  day still know no  other,  than  that  of ablation.   This,
 moreover, is an excision or exsection which is in itself quite an easy
 matter, and which is  performed nearly in the same way  as  for de-
generated hemorrhoids, or for a polypus or any other tumor having a
considerable  base.   Extirpation, which  was recommended also by
 Percy,  completely  succeeded in  the  hands  of Cowper and  Pas-
 quier. # It is unnecessary, however, to remove the tumor as far  up as
its root.  Should we destroy only the two lower thirds of it, the re-
mainder will  invariably re-enter.  Perhaps  in this manner the mus-
cular tissue of the rectum might be respected, and its mucous  tunic
only  divided,  without rendering thereby the  success of the opera-
tion less probable.   The dressing and subsequent treatment scarcely
 differ from those mentioned for  hemorrhoids.  This remedy, as is per-
 ceived,  is sufficiently severe, and so also is it far from bein^ always
 successful.  Though  M. Phelys (Bull, de la Fac de Med., 1808) has
 succeeded, a great number of other practitioners  have failed   Fortu-
nate  is it that modern surgery may almost always dispense with it
 by substituting for it a process which is less alarming and less pain-
 ful, and which only has the disadvantage of not being applicable to
 cases of irreducible prolapsus; and of  being restricted  in its results
 to the retention of the tumor when it has been once returned. 
PROCESS OF HEY AND DUPUYTREN.
777
         Article IV.—Process  of Hey and  Dupuytren.

   This process consists in the excision of the radiating duplicatures
at the  margin of the anus, whether they be or be not occupied  by
hemorrhoidal tubercles.  It appears certain that in' the majority of
cases the obstacle to the cure lies in the dilatation of the sphincter or
a considerable degree of relaxation which has taken place in its mu-
cous membrane and in the skin which is continuous with it externally.
The cellular tissue which lines them acquires finally so  great a de-
gree  of  pliancy, that  it enables them  to glide with the  slightest
effort  over those layers to which they are  naturally adherent,
and to whose movements  only  they are  restricted, when  there  is
no disease  present.  The ablation of a certain  portion of the cuta-
neous  tissue has a surprising effect in removing this anomaly or  in-
convenience, and becomes in this manner the remedy for the disease
which so frequently results  from  it.  The idea first suggested itself to
Hey in  1788, in  the case of a Mr. W.,  of Hull, who had  been for-
merly treated by Sharp, and in whom the anus after the reduction
continued  constantly to be surrounded by a thin, pendant cutaneous
duplicature (thin pendulous flap) which was from 8 to 12 lines long,
having on  its inside, near its base, several  soft and bluish-colored
tubercles, similar to those which are seen in persons who have been
a  long time affected with hemorrhoids.   " It  appeared to me,"  he
remarks, "  that the prolapsus was owing  to the relaxation of the very
lowest portion of the intestine and of the cellular membrane which
unites  it  to the surrounding tissues."  This remark was a ray of light
for the author.   He considered  that in order to cure his patient,  no
other remedy was necessary than that of strengthening the adhesion
of the tissues around the  anus, and  the appropriate action  of the
sphincter itself.   Nothing appeared to him better calculated to fulfil
this intention than the  excision  of the tegumentary flap and of the
tubercles which  were found  appended to it.   He  hoped  by this
means to cause an inflammation which would be  capable of pro-
ducing a more solid adhesion of the rectum with the surrounding
parts, and did not doubt that a  circular wound would  necessarily
bring  about a greater  degree of constriction of the sphincter ani.
Hey removed therefore the pendant bourrelets and the bluish tuber-
bles by means of a bistoury.  The operation was performed on the
13th November, and M.  W. wrote to him in March, 1789, that the
cure continued perfect.   A  second patient operated  upon  in the
same manner, in  1790, was restored in three weeks, though the ex-
cision wds  only made upon one side.  In April, 1791, Hey again had
recourse to his  process, and removed the pendant flap, at the same
time encroaching about a quarter of an inch upon the red membrane
which lines the anus.  The success was  no less complete than in the
two first instances.  A lady whom he also treated, in 1799, in such
manner however as to remove,  only after the  interval of a certain
lapse  of  time between the two  operations,  the two soft  tubercles
which were situated on the two  sides of the anus, recovered equally
well and in as short a  period.   Nevertheless the successful results
that Hey met with rested, so to speak, in oblivion, even in  his own
country.   M. S. Cooper, who mentions them, speaks of them in too
    vol. in.                     98 
778
new elements  of operative surgery.
obscure a manner to enable practitioners to derive any great benefit
from  them, and but  for Dupuytren, to whom  the  same ideas  sug-
gested themselves, and who was thereby enabled to construct a me-
thod upon them and to generalize it, they would probably have at-
tracted no more attention in France than they had done in England
up to that period.
  Operative process.—An injection or even a slight purgative should
have  been administered on the evening previous.   The patient  is  to
be placed in the same way as for the excision of hemorrhoids.  The sur-
geon  seizes in succession with a good pair of  forceps, each radiating
fold  which he  wishes  to remove, and excises them with  a sharp
edged pair of scissors from  below upwards, commencing upon the
margin of the anus at about an inch from the sphincter, and termina-
ting at some lines above it.  Dupuytren says that the removal of four
of them is sufficient, one in front, another behind, and  one on  each
side.  I deemed it necessary in one case to  excise six, and in another
eight, because of the  extreme  relaxation of the  parts, and  the great
dilatation  of the anal opening.   It  is unnecessary to  say that we
should give a greater or less degree of breadth  to each strip that we
excise.  We commence the division more  or less below, and termi-
nate it more or less above, according to the condition  in which the
parts  are found.  One of Hey's patients had a hemorrhage, but  I am
not aware that Dupuytren met with  this accident.  As the English
surgeon has not given any detail, either in  relation to his process  or
the dressing, we are not enabled to say whether the  loss of blood he
mentions, is to be imputed to the operation  itself, or to the manner in
which it was  performed.  The  professor of the Hotel Dieu limits
himself to covering the wounds with a plumasseau, imbued  with
ce>-ate, and places no meche, or but  a very small  one in the anus.
In two instances I have adopted  an opposite course.  The meche,
which I introduced to quite a considerable depth into the rectum,
was of the size ot the finger.   I detached several  parcels from  it,
and lodged them  in  each wound, where I kept them separate by
means of coarse lint, and  afterwards  by a large  plumasseau  with
compresses and a T bandage.   My intention  was to prevent the im-
mediate reunion of the small wounds, and to oblige them  to suppu-
rate, in order to obtain an inodular cicatrix, which would be more
elastic and firmer, and adhesions which would be more solid, than those
resulting  from primitive  cicatrizations.   I have  had no reason to be
dissatisfied with my course.  The cure  was complete ; but  I ought
to acknowledge that the more simple dressing preferred by Dupuy-
tren, cannot be much less advantageous, since the patients who were
submitted to this treatment were also restored without any return of
their disease.   To those who are familiar with the difficulty attend-
ing the cure of prolapsus ani, and with the inconveniences which  it in-
volves, the operation which I  have jusfdescribed will prove an in-
valuable acquisition.  One of  the  cases which  most excited my at-
tention when I arrived in Paris in 1820 was  a  successful result of
this kind.  A woman who had been delivered in the surgical wards
of the Hotel Dieu, and  who for  14  years  had never  gone to  stool
without her anus falling down in the form  of a red livid tumor  as
large  as the two fists, was almost instantaneously cured  by the ab- 
CAUTERIZATION.
779
lation of some of the folds of its skin.  M. Paillard asserts that this
operation, which was frequently performed by Dupuytren after  the
year 1815, never failed but in one instance ; and also that this single
failure was  to  be attributed possibly to the process adopted.   On
my own part I have performed it on five patients at the Hospital of
St. Antoine, La Pitie, and La Charite—two were women and  three
men, and its immediate  results  were no less conclusive.  The  same
has been the case with the operation as performed  by MM. Mauge-
nest, (Gaz. Med., 1832, p. 857,) Giorgi, (Journ. des  Conn. Aled., t. I.,
p. 349.) Lutens, de Cock, (Bull. Med. de Gand., t. I., p. 37,) Ammon,
(Bull, de Fer., t. XIX., p.  64,) and Dieffenbach, (Gaz. Med.,  1831,
No. 2.)   M. Heustis also was successful, (Ibid., 1834, p. 777,) by ex-
cising a circular fold  around the  anus.   The  radiating cauteriza-
tions which were formerly used by Moreau, (Saviard, Obs. XIV., p.
55,) in the direction of the duplicatures of the anus, in order  to con-
tract this opening, might moreover have  suggested the idea of  the
method  of  Dupuytren.  I should remark, however, that the  cure is
not always permanent.   In one of my patients there was a return of
the disease at the expiration of a year.   In May, 1839, I saw an
Englishman who  had been formerly operated upon  by Dupuytren,
and in whom the prolapsus had also been reproduced.  If the pro-
lapsus still  shows itself at the first  stools which  succeed to the exci-
sion, it is rarely as marked as it was  before, and returns of itself or
with less difficulty, and soon disappears entirely.  The freedom of the
belly favors the success  of the operation  by exempting the patient
from making as much effort during his stools, and must in consequence
be  attended to  by means  of injections, or laxative  drinks, or mild
purgatives.  Finally, the excision of the radiating folds of the anus
seems calculated to answer for cases of prolapsus,  which are  owing
to a state  of  relaxation of the  mucous  membrane, integuments,
sphincters,  and external tissues; for all those cases in a word which
are not caused by an  organic lesion, or disorganization of some of
the parts contained in the pelvis or hypogastrium; so that the am-
putation of the tumor should be reserved  for those cases of prolap-
sus which are absolutely irreducible.

                  Article V.—Cauterization.

  A means  which acts nearly in the same  wa)- as the preceding ope-
ration is that of cauterization.  Cauterization with the, red hot iron,
which was employed with success  by Ansiaux, (Clin. Chir., 2e edit.,
p. 174,)  in  several patients, and by  M. Philips, (Rev. Aled.,  1833,
t. III., p. 452,)  and M.  Kluyskens, (Gaz.  Mid., 1834, p. 777,)  has
been again  eulogized by M. Burgraave, (Bull.  Med. de Gand., t. I.,
p. 37,) as one of the most certain and  easy modes of remedying
prolapsus ani.   First proposed by Leonidas, it had  also been extolled
by Marchettis and Psyter; but I can scarcely conceive what advan-
tages it can have. 
780
NEW ELEMENTS OF OPERATIVE  SURGERY.
   Article VI.—The  Intestine protruded through  the Anus.

   Twelve inches of intestine, which had protruded through the anus,
were successfully  reduced by Lacoste.  These kinds  of prolapsus,
which have been  mentioned' also by  F. ab Aquapendente, Muralt,
Saviard, Sabatier,  Puy,  G. Roux,  Salmuth, Starke, Martin Solon,
Lambert, Hagen, Lettoom, Castara,*&c, almost always terminate in
a fatal result.  It is said however that a patient  was cured by tearing
off himself the invaginated mass, and I have already quoted, while
speaking of extirpation of the uterus, the singular history of a woman
who was said  to have survived the destruction of the uterus, vagina,
and rectum.   The reduction and the retaining  of the parts which I
have spoken of farther back, are nevertheless the first remedies to be
made trial of in these cases.

                    Article VII.—Fissures.

  The fissure  or crevasse of the anus  is a  small narrow elongated
ulcer which developes itself between the radiating folds of the funda-
ment, and causes in the majority of patients the most acute pain.
The most ancient authors speak of it in such vague terms, that no
person, before  the researches of Boyer, thought  of separating it from
the other anal ulcerations.   Aetius, in  mentioning it, appears how-
ever to have already had reference  to constriction of the  sphincter.
Avicenna enumerates the causes of it, without having had any very
distinct conception  of its character.  Albucasis,  who points out its
treatment in detail, imputes it to constipation of the belly and to the
desiccated state of the  stercoral  matters, and Grueling does not dis-
tinguish it from  the ordinary rhagades, though he had already as-
similated it to the  crevices seen on the hands of servants during
winter.   Lemonnier, the first writer who has distinctly described it,
compares it, like Grueling, to the cracks upon the hands or lips, and
accurately defines  its  seat, but does not establish its  mode of treat-
ment.  Sabatier  makes only a slight allusion to it in his Medecine
Operatoire, while all the other authors of repute, both abroad and in
France, down  to the present times,  have given  no description of it.
It was not however because it is a rare disease, for Boyer, in 1825,
announced that he himself had already  met with 100 examples of it.
I myself have  noticed more than 30  cases of it.  But up to that time
its origin  had. been imputed  to affections altogether different, to the
venereal disease, hemorrhoids, disease  of the bladder,  to a blind or
a complete and concealed fistula, a preternatural incurvation of the
coccyx, and even to the existence of a cancer, either of the uterus,
prostate or rectum.   The description which E. Home gives of the acci-
dents caused by the engorgement of the lateral  lobes of the prostate
might also well be classed under  this head.  " There is,"  says this au-
thor, "a  great difficulty in going to stool, and a tenesmus, accompa-
nied with violent pain, which is increased by the  efforts which the pa-
tient makes to relieve the intestine." The table which  M. Copeland
has given, of what he calls spasmodic contraction  of the sphincter, also
appears to me, at least  in great part, to have reference to this disease
It  has frequently  been confounded with  the  rhagades and  other 
FISSURES.
781
 superficial exulcerations of the anus.  The remarks of Guy de Chau-
 liac and  Dionis  in reference to it leave no doubt  on this subject.
 Thus  fissure at the anus was not in  reality known as a distinct dis-
 ease until after the year 1822.   M. Blandin believes with M. Hervez
 de Chegoin that the  fissures  situated below or above the sphincter,
 constitute a disease of little importance, and one which is cured by
 simple means or disappears spontaneously, while the others only  pre-
 sent all the series of  inconveniences presented by Boyer.  But  this
 distinction is  purely theoretical.   Among the patients whom  I have
 seen there were many in whom the crevasse had given rise to exceed-
 ingly violent pains, though it  was entirely disconnected with the mus-
 cular ring which surrounds the termination of the rectum.  The con-
 striction of this muscle is a point which requires special elucidation. Is
 it the  cause or is it the effect ?  Boyer, upon the strength of the  fact
 that he has several times encountered the constriction without fissure,
 that he has never seen the fissure without constriction, and that the  sec-
 tion of the .sphincter, even without touching the fissure  immediately,
 causes the accidents to subside,  adopts and defends the first opinion.
 Others, basing their opinions on the ground that the ulceration may
 exist without  its being possible  to perceive it, pronounce themselves
 in favor of the second opinion.  It cannot be denied, in fact, that the
 fissure may sometimes take place without constriction, though it may
 be at the same time accompanied by its other  symptoms, four or  five
 examples of which have fallen  under my own observation.   Again,
 who could assert that the fissure was wanting, merely  from the  fact
 that it has not been  found ?  The case related by M.  Louvet is in
 reality of no weight,  since the patient was not even explored.   The
 confidence which is due to the  experience of Boyer, is in fact, the
 source of all the value  attached to the observations he adduces in
 support of his opinion, for the truth of his assertions has never been
 verified in the examinations of the  dead body.   The  practitioner,
 when he reflects that  a crevice irritated by the passage of alimentary
 matters, may cause a spasmodic contraction of the subjacent muscu-
 lar fibres, and that it is  inconceivable how a muscular constriction
 can produce a fissure, will, as it  appears to me, accord his  adherence
 by preference to the second opinion.

                           § I.—Signs.

   The accidents which denote a fissure are of two orders, viz., those
 which have reference to the  disturbance of the functions, and those
 that relate to the appearance of  the parts themselves.  This disease,
 when it exists in  an  extreme degree, is accompanied with excrucia-
 ting torments.  At the moment of going to stool, the patients compare
 their pains to those which would be produced by the introduction of
 a red hot  knife into the anus.  This sensation of burning exists some-
 times to such degree, that it produces the most inconceivable anguish,
 with symptoms of convulsions, and accompanied with syncopes.  To
others it appears as if some person was tearing out the fundament.
During the interval between the stools, they sometimes experience
only a burning sensation, lancinating pains that are more or  less
acute, a sense  of weight, and  some symptoms of colic.  As the  stools 
782
NEW ELEMENTS OF OPERATIVE  SURGERY.
approach, however,  the pains sensibly augment, and  do not reach
their extreme point of violence, except at the moment  of the expul-
sion  of the matters,  after  which they continue to diminish  during
the space of some hours.  The constipation becomes so obstinate,
that  the  alvine evacuations  would only take place at intervals of
8,  10, or 12 days, unless they were  solicited.   The patients dread-
ing them beyond any thing that can be imagined, recoil from them
at  the moment they are to  take  place as much as possible.  Never-
theless, they are aware that their infrequency renders them so much
the more painful.  One, two, three, or four injections, which  are
sometimes required to procure a single evacuation, at other times are
wholly insufficient.   Purgatives alone, administered by the  mouth,
succeed in opening the belly.  Hence there are certain patients who
feel themselves  under the necessity of taking a cathartic every other
day.   A  lady who was treated by Boyer, had come to the determi-
nation of keeping  a canula  fixed in her anus.  A patient at the Hotel
Dieu, stated that he would much rather die than  go to stool again.
The liquid state itself of the matters does not in all patients exempt
them from suffering, as is proved by a case related by Boyer.  Though
some may walk, or seat themselves, or attend  to  their occupations
for several hours in the interval  between their paroxysms, others are
obliged to keep  their  bed, though it  becomes a source of distressing
irritation and fatigue  to them. The lancinating pains extend towards
the bladder or the uterus, according to the sex, and even reach in
certain cases the highest part  of the  hypogastrium ;  the products of
digestion become altered ; the patient eating but little, from apprehen-
sion of having  stools, loses his  natural color; and  his features soon
express the  sufferings he  endures, in so marked  a degree, that it
would be supposed he was laboring under a profound organic lesion.
In  respect to the anus, the introduction of a syringe, meches, canulas,
or  a foreign  body of  the smallest size, reawakens  the  apprehension
of the alvine evacuations.  The pain occupies quite a circumscribed
space of  the contour  of this opening, and is frequently accompanied
with pulsations similar to those which would  be  produced by a
phlegmon.   The finger encounters  here a  constriction which can-
not be  overcome without producing the most severe exacerbation.
When  we press on any given point of the interior of the sphincter,
the pain  immediately acquires such a degree  of acuteness,  that it
draws forth piercing cries from the patient.  If we separate its folds
apart, the eye finally  perceives at the  bottom of one of the grooves
which lies between them, a small ulcerated  fissure, one to two lines
broad,  and from four  to eight  or ten lines long.   Its borders are usu-
ally neither callous nor tumefied ; and its surface in quite a number
of  cases  is of a very bright red color.  In this respect we  cannot
convey a more exact idea of it than  by comparing it to the chaps
which are seen  on the hands and feet, in country people during win-
ter, much more than  to those on the lips.   Different from rhagades
and  other  exulcerations, it gives out scarcely any exudations?  and
rarely  stains the  linen.  The contrary of this however sometimes
takes  place; in a small number of cases  there sometimes  exudes
even streaks of blood with the fasces, but these occur only as exceptions
Fissures  of the anus,  from being concealed  between the tegumentary 
FISSURES.
783
duplicatures, are not always readily discovered.   We can only de-
tect them in certain cases by means of the closest examination, and
by spreading out the skin of the  fundament with  the greatest  care,
and by making the patient protrude the anus a little, as if  for the
purpose of going to stool; in most of the cases the anus is retracted to
a great depth.  The situation of the fissure, moreover, has no fixed lo-
cality.  Though ordinarily on the  side and to the right or left, it is also
sometimes seen behind or in front.  In some cases it is so low down
as scarcely to reach the beginning of the mucous  membrane  above,
or it may be placed so high up above the sphincter as not to reach
the skin below.  It is not unfrequent to find a hemorrhoidal tubercle
forming, as it were, its root, and receiving, so to speak, its tail.  Most
commonly, however, it is situated in such manner that its commence-
ment is located  upon the entrance of the anus itself, while its other
extremity reaches  to a greater or lesser extent towards the intestine.
When not distinguishable by the  eye, the finger passed around  upon
the different points of the anal  circle  above and below, may be
more fortunate.  If there is a fissure, the pain becomes poignant as
soon as it is touched.  A  hardness, the  appearance of a  tense  cord,
and rugosities that are more acutely sensible  than the remainder of
the intestinal opening, indicate its presence.   But this mode of ex-
ploration  is not in reality indispensable, except the  crevice is too
high up to allow us to draw it down so  as to expose  its  location to
view.   We shall not moreover confound an alteration of this kind
with organic coarctations  of the rectum, if we  take  care to notice
that the suppleness of the tissues is preserved, and that we experience
a  sharp, sudden contraction,  instead of a  permanent  constriction
with degenerescence of the parts.  It is too easy to distinguish  it
from internal or external hemorrhoids with or without excoriations,
also from  chancres and other ulcers, and from fistulas and affections
of the prostate or of the bladder, or sexual organs in women, to make
it necessary for us  to dilate upon its differential  diagnosis.  Three
essential symptoms therefore  characterize  fissure  at  the  anus: 1st,
burning pains at the moment of passing the stools; 2d, a superficial,
narrow, long ulcer, or sort of crevice, at the entrance of the intes-
tine ;  3d, a violent and painful constriction of the  sphincter, without
any appearance of organic lesion.  Moreover, it is not accompanied
in all cases  indiscriminately with the long  catalogue  of  phenomena
which we have just described.

                        § II.—Treatment.

   Fissure at the anus, if left to  the resources of the system, may
endure to an indefinite length of  time.  Since it has been examined
with care, it  has not yet been possible to ascertain in an authentic
manner that it  has ever been cured without the  aid of art.  The
patients exhausted by their sufferings, fall into a state  of wasting
decay  and thus succumb, or ultimately  become  attacked with  some
incurable  organic disease.  An English  lady who  had rendered her
life supportable for several years,  says Dupuytren,  by the  use of calo-
mel, did not effect  a cure.  Baths, leeches, bleeding, calmants,  anti-
spasmodics, purgatives, lavements, and injections of every description 
^84          NEW ELEMENTS OF  OPERATIVE SURGERY.
furnish no better sources of relief.  Nothing will succeed, according
to Boyer, b'U the incision of the sphincter.   On this subject we must
understand ourselves: simple fissures  unaccompanied with constric-
tion, whether they be syphilitic, hemorrhoidal or dartous. or  of any
other nature, evidently yield  to milder means.   The ancients, who
confounded all of them under one designation, could not have been
always deceived in speaking of their pomades  and  other medica-
ments.  Before laying it down as a fact that this or that medication
has cured  the patient, it becomes necessary, if we would not repro-
duce the confusion  which, in this respect, has so long  existed in sci-
ence, to give positive demonstration  that the fissure  was actually
accompanied with a constriction of the sphincter.  But  this unfortu-
nately has not been done in the majority of cases  published up to the
present time.  M.  Blandin, for example, in saying that the  fissure
has callous borders and a grayish bottom, and in  distinguishing  it
only by its seat in place of endeavoring to discover its nature, would
reproduce, doubtless unintentionally, the obscurity which was  so hap-
pilv dissipated by Boyer.  For myself, I wish to be  understood as
speaking here only of a true fissure or  painful crevice at the anus.
  A.  Various Medications.—I  cannot understand why Albucasis,
who recommends that we should abrade the fissures with an instru-
ment  or the  nail until they are  made to  bleed  or tumefy, or why
Guy de Chauliac and Dionis, who cauterized or scarified them, may
not have also succeeded  in curing them in some  cases, if it be true,
that  in our days Guerin has eradicated them with  the red-hot iron,
and that the nitrate  of silver has frequently succeeded ; nor can I share
with the moderns in their aversion to  such remedies.   A species of
balsam which usually soothes, but with which Boyer obtained suc-
cess  in one instance  only, which, however, was only a case of mild
constriction, is made of the following materials ;  hog's lard, syrup of
rhubarb, syrup of nightshade, and oil of sweet almonds each, 5 ounces.
Some spoonsful of this  are  injected  into the rectum with a small
syringe two  or three times a day.  It is  probable that the  blanc-
rhasis, and most of the pomades recommended by the ancients, pos-
sessed the same qualities.   Dupuytren appears  to have made use
with advantage of a mixture of extract of belladonna  two ounces,
water sweetened with honey two ounces, and  hog's lard two ounces,
which was introduced into the anus  upon a meche besmeared with
it.  M. Descude says that we may cure the fissure by administering
oil of hyoscyamus in large doses by the mouth, at the same time that
we employ  mercurial ointment as a  topical  application.  M.  La-
moureux (Soc Med. de  la Seine-Infer., t. IX., p. 78,) states that he
has succeeded by  employing belladonna, or repeated lotions,  as  is
recommended by  Mothe, (Arch. Gen. de  Alid., t. XVII., p. 648.)
Douches of cold watgr and decoctions of chervil or of poppy heads,
have  also been extolled.   I have succeeded in two or three  in-
stances in  causing  the fissure to be besmeared morning  and evening
with a pomade of white precipitate one drachm, and hog's lard one
ounce.  But  the three remedies which  have been most zealously re-
commended for some time past have, nevertheless, been cauterization
with the lapis nfe  nalis, dilatation and  the section  of the sphincter.
  B.  Cauterization.—By attacking the whole extent of the fissure 
FISSURES.
785
with a  crayon of nitrate of silver, we may hope, by changing the
condition  of the surfaces, as  was done by rasping, excision, or the
actual  cautery, to  transform  it into a simple wound.  Beclard, who
stated  that  he had  employed this method with a success almost un-
varying, was, however, opposed before the Academy by M. Richer-
and, who  affirms that he never derived any benefit from it at the
hospital of St. Louis.  Three of the patients, also, in whom I made
use of it not having obtained the slightest relief from it, I was induced
to believe that Beclard had only had recourse to the nitrate of silver
in fissures without constriction, or that his successes were to  be at-
tributed to the dilating meches which he used at the same time; but
the cures which I  have since obtained by the aid of this means in
decidedly marked cases of fissure, oblige me to change my opinion.
   C. Dilatation.—The employment of meches  of lint gradually in-
creased in size, until they overcome the resistance of the sphincter,
appear  to have had  more efficacy.  Beclard himself states that he
had reason  to  be well  satisfied with them.  M.  Marjolin and MM.
Nacquart  and Gendrin, also appear  to  have obtained unquestionable
cures from this remedy.   The great point is not to diminish after the
first, but to increase them rapidly to the largest size possible, what-
ever may  be the resistance of the  sphincter ; the pain, which is ex-
cessively acute during the first hours, afterwards subsides by degrees,
and disappears in a great part before we have reached to the fourth
or to the fifth meche.   There is no objection, moreover, to the dilating
body being besmeared with one of  the pomades above indicated.  I
cannot, meanwhile, withhold  the comparative experience that I have
had in this treatment, though  I have yet made but  three trials with it.
Ordinary meches besmeared with Boyer's mixture, have effected nei-
ther more nor less than the pomade of Dupuytren, or that with bella-
donna and opium without acetate of lead, or that of mercurial ointment,
either simple or in combination with opium.  Having obtained no ame-
lioration from the employment alone of the populeum ointment, blanc-
rhasis, pomade  of precipitate, and  cauterization  with nitrate of sil-
ver, I  put the  dilating meches to  the test,  sometimes besmearing
them with cerate only, and at  other times with  the medicated po-
mades, when the result proved to  be decidedly the same in both
cases.   Copeland had already employed dilatation in spasmodic con-
striction of the anus, and I am of opinion that those physicians who
would  have  sufficient resolution to engage their patients not to give
way before  the first suffering, might obtain decided benefit from it.
The three cases which have been published by M. Mondiere, (L'Ex-
per., t. III., p. 234,) come in support of the opinion which I formerly
expressed on this subject.
   D. Incision of the  sphincter, as  proposed by  Boyer, and  since
adopted by  almost all surgeons, is the means which, up to the  pre-
sent time, has procured the  greatest number of  cures; so much so
that its inventor considers its success almost infallible.  Beclard and
MM. Richerand, Roux, and Lagneau, however, have cited cases in
which it had failed in their hands.   Consisting of  a  deep incision on
one or both sides of the anus, necessarily makes it a resource which
must be of an extreme character, and one which  patients do not al-
ways assent to without much opposition.   We ought not therefore
  vol. hi.                      99 
786
NEW ELEMENTS OF OPERATIVE SURGERY.
 to propose it, except as a dernier resort, and  after having unavail-
 ingly made use of the other  operative methods.   The preparatives
 which are then similar to those of the operation for fistula, still more
 imperatively  demand that we should cleanse out  the  large intestine
 on the evening before, and two or three days in advance, by the aid
 of injections and mild purgatives.  The articles, which are composed
 of a straight, blunt-pointed bistoury, and  an  ordinary straight bistou-
 ry, a large meche, a  T bandage and all the  essential  accompani-
 ments, being  arranged in order,  and  the  patient  laid upon the
 edge of a bed, with his head depressed, the under  thigh stretched out
 and  the other bent, and his two buttocks stretched wide apart by the
 assistants, the surgeon then introduces the forefinger of his left hand
 as far in as beyond the sphincter, and  using it as a guide  to glide in
 flatwise  the  blunt-pointed bistoury to  such depth as is  required,
 immediately  proceeds to  make the incision.  Though  the  fissure
 ought in some respects to be the locality  of the wound, it must how-
 ever, in consequence of the urethra or vagina, be left intact, should
 it be  situated  on  the median line  in front.  Boyer considers that  it
 will  always be found sufficient to divide the muscle on  one of its
 sides without paying attention to the fissure; but prudence, if not
 necessity, as it appears to me, makes it preferable that the bistoury
 should make  the  incision  in  the  fissure when the latter can be dis-
 covered.  We then  prolong  the incision upwards  and downwards
 with the straight bistoury, for an  inch  or two upon the skin, and in
 such  manner that the entire  thickness of the sphincter  may be di-
 vided.  Unless there  should  exist several fissures,  or  that the con-
 striction extends  to  too great a  distance, a single incision will be
 found sufficient.   Otherwise we make one on each side, and accord-
 ing to the same  rules.  If the  borders  of the cleft  are  callous or
 rounded, we  seize them successively with  the forceps,  and excise
 them with a single  stroke of  the bistoury  or scissors.   After this
 there is nothing to attend to but the dressing, for  hemorrhage  under
 such circumstances is almost impossible.  The operator immediately
 introduces the meche and causes it to  enter  to  an inch at least be-
 yond the superior angle of the incision. After having detached  some
 portions  of it, and placed them in the wound, he fills up the inter-
 gluteal  groove with coarse  lint  or  with gateaux;  places  a  few
 long compresses over this; then supports  the whole  by a T bandage
 and causes the patient to be carried back to his bed if he had been
 removed from  it.  The  subsequent treatment and other  dressings
 are the same  as in fistula.                                       s
  Relative value of the different methods.—-In fine, fissure of the anus
 appears to be susceptible of a cure in various ways.   Its lips by beine
 kept eithei  in perfect contact or  completely  separated apart durinl
a certain length of time, allow of cicatrization  by the first intention,
or admit of the thorough  cleansing of  the  wound.   The pucker-
 ing of  the anus, or the  constriction of its sphincter, by spread-
ing open or approximating its walls on the  slightest movement de-
stroy m this manner at every moment the  conditions that are  indis-
pensable for its consolidation.  Caustics  and excision, by imparting
to it the characters of a recent wound, ought to favor itL<XS
 tion and thereby possibly  effect a cure in a certain number Sf cases 
FISSURES.
787
 though they may not therefore be a radical remedy for it.  Unguents,
 pomades, &c., being capable only of modifying its nature or surface
 must on  that account alone succeed still less frequently.  Dilatation
 by forcing the duplicatures of the fissure to spread out, obviates its
 constant  laceration, prevents the irritating matters from becoming ar-
 rested  and stagnating between its lips, and enables it to close in the
 same manner as a simple excoriation.  If the incision acts directly
 upon the fissure it is immediately merged in the remainder of the
 wound and no longer presents any peculiar feature.  When the sphinc-
 ter has not been divided by the instrument, its fibres in retracting
 approximate  the walls of the wound, and thus  obliterate it in such
 manner that no particle of matter can glide in between them, so  that
 time is given them to become solidly agglutinated before the  anus
 has resumed its usual functions.  Thus in theory as in practice, in-
 cision is the  method which presents the best chances of success; but
 this operation is not exempt from every danger, though in general it
 is easy and may consist of nothing more than a simple debridement.
 If Boyer has never been disappointed in his expectations, there are
 others who have been less fortunate.  In my knowledge two patients
 have died from this  operation.  One who was a young woman of
 strong and robust constitution did not succumb until after the lapse
 of several months.  Adhesions had become established  among the
 organs of the pelvic cavity, and the cellular tissue in the neighbor-
 hood of the  intestine contained pus in a state  of infiltration.   The
 other, who was  a man 35 to 40 years of  age, was seized  on the 12th
 day with  a violent  entero-peritonitis, and died in my department at
 La Pitie,  in the month of  November, 1831.  A considerable number
 of purulent  collections were  found  under the peritoneum of the
 pelvis.  The incision of the sphincter, however, had  been  attended
 with no peculiar circumstance.  If the idea of a large sized meche
 alarms the most of those to whom it is proposed, the introduction of
 the finger, which must precede the incision, is scarcely less repugnant
 to them.  Perceiving in  the first case that their sufferings diminish
 instead of augmenting, they soon recover  from their terror;  while
 in the second case they have to dread, in addition, the consequences
 of a bloody operation.  Prudence, therefore, would seem to dictate
 that we ought to make trial, in succession, of some of the principal
 topical applications recommended, and even the nitrate of silver and
 the dilating meches before we proceed to the incision.
  E. Excision.—With the view  of avoiding  the division of the
 sphincter, I deemed it advisable to suggest the excision of the fissure
 itself.  This  method, which was extolled by Mothe and Guerin, and
 which I had already indicated  in 1832, has now been frequently per-
 formed.   Some  of the essays  which I made were published in  the
 year 1836, (Demonge, France  Med., 1.1., p. 46.)   Everything being
 arranged  as above described, I seize the fissure with an erigne, then
isolate it on the right  and leftwith a  cut of the  bistoury, or simply
extirpate it entire with a  good pair of scissors.   By this  means  the
muscular tissue is respected, the operation but little painful, and  the
wound cicatrizes promptly, while the dressing  is the same as  after
the incision.  I ought to  add,  however, that two of the six patients 
788
NEW ELEMENTS OF OPERATIVE  SURGERY.
 whom I treated by excision had the fissure reappear and have never
 been completely cured.

                    Article VIII.—Fistulas.

   Fistulas in the anus, in the same way as the abscesses which pre-
 cede them, present  themselves  under very variable  characters.  I
 shall not occupy myself with those which are caused by some altera-
 tion in the bones, or some deep-seated  lesion in  the  interior of the
 pelvis, or abdomen, or in the genito-urinary organs.  The only point
 under consideration here is those fistulas that are kept  up by the con-
 dition of the  lower portion of the rectum.   Authors have admitted
 three varieties of these :  1st, complete; 2d,  external blind ; and 3d,
 internal blind fistulas: the first  having two orifices, one at the ex-
 terior and the other in the anus; the second opening only externally,
 and the third only in the interior of the intestine itself.

                         y* I.—Varieties.

   Though the existence  of complete fistulas  has never been ques-
 tioned, it is not the same with the others.
   A. Foubert, and afterwards Sabatier, who were disposed to  be-
 lieve that there were no external blind fistulas, asserted that the  ab-
 sence of an internal  opening was explained by the examination hav-
 ing been in  such cases badly conducted.   To this remark it may be
 replied, that one means of always detecting it, as  some practitioners
 flatter themselves, is to make one complete with the sound or explo-
 ring probe, when there is  none in reality.  Their doctrine, founded
 upon the principle that fetid abscesses  of the anus  are always caused
 by a perforation of the rectum, has no longer need  of being combated
 at the present day.  The more the rectum has been attenuated, what-
 ever may  be the extent of the abscess, and the slower has been  the
 destruction of the cellular tissue, and the more  extensively it has
 spread m the  ischio-rectal depression, or the more impaired the pa-
 tient's constitution is, or the more it is  implicated  in those affections
 which modify the entire organism, the more is this kind of fistula to
 be apprehended after abscesses of the  fundament; so  that external
 blind fistulas far from being  impossible, are, on  the  contrary, ex-
 tremely frequent.                                          J'
  B Internal blind fistulas  have also  been rejected by a certain
number of authors   It would seem, in fact, that it is not allowable
 o admit of  them but as a point  of departure for complete fistulas
In the theory o Foubert for example, it would be difficult to conceive
 hat when the  intestine is opened into,  there would not be formed a^
abscess which would soon become apparent externallv, or that™ ecol"
lection could pour out its pus into the interior, over a certatonumber of
days, without also making an external opening  Exner ZS
sent time has produced a perfect ^i^ffi "*»%»
observations are even calculated to make me cons der internaf blmd
fistulas quite a common disease.   They are reduced, it isTue to a
cavernous ulcer, whose pus is poured out into the  rectum    col
 quence of  the pressure of the surrounding parts, but which may pe?- 
FISTULAS.
789
 sist for months without making any manifest progress towards the
 skin.   I have now seen at least a dozen examples  of them.   If the
 orifice  is not very large, and situated below the dilated portion of the
 rectum, this in itself may be but very slightly irritated by the faeces,
 for the  stools tend rather to  close it up than to enter into it as they go
 out.  We thus perceive that all discussion on  a  subject of this kind
 will be henceforwards confined to a dispute about words.
   C.  A complete fistula is not always simple ;  quite frequently there
 will be found one on each side.   In other cases also it may have a
 greater number of openings externally,  though there may be but one
 only in the interior.   In certain cases it is pierced, as has been re-
 marked, in the manner of»the spout of a watering pot.  Its intestinal
 opening, which in most cases consists of one only, has scarcely ever
 more than this when there  is but one opening only externally.  In-
 stead of following a uniform direction, its track is frequently sinuous.
 The one on the left side for example may pass to the  right.  Its pre-
 sence in front does not prevent it from having its origin behind, and
 vice versa.  After having proceeded  in one direction, it may hap-
 pen that it will take another route, and form  various angles before
 terminating at the skin.  If a simple opening  externally may some-
 times receive  various branches, it is still less rare  when a patient
 has several passages, to find them all converge with more or less uni-
 formity towards  the  perforated intestine.  In place of one sinuous
 track,  there may  be  sometimes found  between its two extremities,
 passages of greater or less calibre, which are prolonged sometimes to-
 wards  the ischium ;  sometimes above  the coccyx and  glutei mus-
 cles, and towards the sacrum, and  into  the pelvis;  or at other times
 also they may surround the whole contour of  the termination of the
 rectum, which latter is then suspended,  as it were, in  the centre of a
 vast purulent cavity.
                              y  II.

   The precise situation of the internal orifice  of  complete fistulas
 has become during the last half  century the  subject of a very spe-
 cial investigation.   The ancient authors, the entire Academy of Sur-
 gery, and Desault himself and most of his  pupils, without appearing
 to suspect that such a principle could be contested, had maintained that
 we would find the rectal orifice of the fistula sometimes  in  close
 proximity to, and at other times at quite  a considerable distance from
 the anus.  M. Ribes, on the contrary, maintains that it  is always or
 almost always situated above the external sphincter.  This doctrine,
 advocated by M. Larrey, who like M. Ribes ascribes it to Sabatier,
 belongs entirely, if M. Pleindoux is to be believed, to Brunei, a phy-
 sician of Avignon, who  defended  it  in the year  1783 in a special
 treatise on the subject of fistula.  In respect to  Sabatier himself,
 there is reason to  be  astonished at the silence which he observes  on
 this subject.  It was in fact  to  be expected, after the language which
 M. Ribes imputes to him, that we should  find him develope his opinion
 in detail in his Medicine Operatoire, in  which work  he says not a
 word of it.  However this may be, the assertions of M. Ribes, from
 being supported upon numerous facts and  careful dissections, could
not fail  to attract the  attention of investigators.  M. Roux and Boyer 
790
NEW ELEMENTS OF OPERATIVE SURGERY.
 still contend that there may be fistulas situated very high up, while
 M. Richerand has completely ranged himself under the new opinions.
 After  the examples of those masters in the science, I desired to as-
 certain myself what was the truth  in  this  matter.  Out of thirty-
 five cases of fistulas which I was enabled to examine for this  pur-
 pose, in the year 1833,  either upon the dead body or during  life,
 I  found four in which the ulcer in  the rectum  was as  high up as
 an inch and a half, or two or two and a half inches, and consequently
 a  little above the external sphincter.   A fifth example  among these
 fistulas, even  reached  as high as over three inches,  for it could
 scarcely be reached  by means of the  finger, but this  was  after it
 had made a long track between the mucous membrane and the other
 tunics  of the rectum.   The others opened  at the  entrance of the
 anus or at  a few lines  within it,  in conformity  to the opinion of
 M.  Ribes.   Three of them even had  their orifice outside of the
 villous membrane of  the anus, and two  only were found  a  little
 nearer to the valve of the sphincter than they were to  the  integu-
 ments.  I could at the present day enumerate as many as a hundred
 cases of this description, and in which  the same distances were al-
 ways observed.   Thus experience, which concurs with the anatom-
 ical explanation which I have elsewhere given in relation to this mat-
 ter,  (Diet, de Med., 2nd edit., art. Abces de VAnus,)  authorizes us in
 asserting that certain fistulas may open upon the skin  itself at the
 entrance of the  anus ; that most of them have their  orifice between
 the sphincters, and that  it is  also not very uncommon to meet with
 them at a short distance above.  In remarking the distance to which
 the intestine is occasionally  separated above, we find moreover an
 explanation  of the reason why so great a number  of practitioners
 have not thought of searching so low down for these openings.   In
 fact, the probe  separated from the forefinger only  by the mucous
 membrane itself, will ascend sometimes without the  slightest effort,
 in  the same  way as  it would  between two sheets of paper, as high
 in  a great number of cases as to the distance of two or three inches
 in  the direction towards the pelvis, though the fistula may be situated
 at  some lines only from  the anus.   This circumstance  arises from
 two causes : 1st, because the  inner membrane of the rectum being
 denuded of its  cellular tissue, easily allows itself  to be separated by
 the  instrument  which glides  between it,  in such  cases, and  the
 muscular coat, in the same way as it would between two pieces of
 wet linen ; 2nd, because the pus of the fistula  or the humidities of
 the intestine, intercepted by the internal sphincter below, and by the
 external  sphincter outside,  find  more  facility in takin^ a reflux
 course  upwards, between the coats of the intestinal tube itself.

                       y III.—Diagnosis.

  The  recognition of fistulas in the anus is rarely attended with  anv
difficulty;  their differential diagnosis  only sometimes presents some
degree  of embarrassment   Whether they be complete or incom plete
there always exists, provided they have an external opening, an ulcer
at the margin of the anus.  This ulcer has been preceded by an abscess
or  by hemorrhoids in a state of inflammation  in the  greater number 
FISTULAS.
791
of the  patients,  and has already existed for  a period of several
months.   Some  persons  however are  unconscious of  its origin,
and  have been affected with it for a long time without  having been
aware of it, considering themselves to  be laboring only  under fluent
hemorrhoids, either internal or  external.  A  small projection  or
tubercle of variable size, quite frequently conceals its orifice, which
latter, in other cases, is hidden at the  bottom of a kind of lacuna.
Pressure usually causes a small quantity of pus to escape from it.
The matter which  comes out from it, and which stains the shirt of
the patient, is sometimes of a reddish color, and, as it were, sanguino-
lent, sometimes  ruddy and exceedingly limpid, while at other times
it resembles greyish  and  serous pus.  This ensemble of characters
however, also belongs equally to a fistulous ulcer and to an external
blind, as well  as  to a complete fistula.   The fiscal odor emitted  by
the matter, or the linen which is imbued with it, is perceived alike in
both  cases.   The escape  of gas would be a more conclusive sign,
were not the air, which is introduced  into the fistula while the rec-
tum is  empty, and when pressure from without  inwards or from
within outwards  can  cause  it to  be expelled, of a nature frequently
to deceive on this point.  In order to demonstrate with certainty that
there is actually a fistula, it  is necessary that certain particles of the
substances which pass through the digestive tube should have made
their escape from  the ulcer; that  we  should have seen worms or
other foreign bodies,  or stercoral  matters, or a portion of the liquids
thrown up in the injections, make  their exit from it;  and that the
patient,  at the time of going to  stool, should  have perceived that
wind or  humid matters were passing through  as they entered from
the rectum.  Such  signs, it  is true,  are  sufficient to remove  all
doubts;  but  as fistulas are  not all  accompanied  by them, and as
they  are moreover purely rational, the  surgeon is obliged  to have
recourse besides  to  those  furnished  by the probe and by phy-
sical indications.  The  exploration then  requires  that the  patient
should be laid down  in the  same way as for receiving  an injection.
The  left forefinger introduced into the anus, proceeds at first in
search of the internal ulcer, which is  recognized  without  difficulty
if  it is large, and which, if it is narrow, is quite frequently indicated
by a pain somewhat more acute, or by a small protuberance like a
pullet's  rump, but not always, as Pelletan thinks.  The right hand
then  introduces the probe,  which ought to be smooth and blunt-
pointed,  and small and flexible,  unless  the entrance of the fistula
should be so large as to require but little precaution.  The void
which it meets with shows in which direction we should push it.   If
the exploring finger has found the internal opening, the remainder of
the search is not difficult.  In the contrary case the operator, always
acting without any effort, leaves the instrument to  penetrate, so to
speak, of itself, makes it pass around the whole extent of the morbid
cavity, and  brings  its point  towards the anus and between the two
sphincters, if it has not already been directed to that region in  the
beginning ; then follows its various movements on the contour of the
intestine by means of the finger  which  he has introduced into  the
anus, and does not withdraw it until after he has in vain searched
ir*o the different recesses and all the deviations, sinuses and passages 
792          NEW ELEMENTS OF OPERATIVE SURGERY.
of the fistula;  or until he has positively ascertained  in some way
or another the situation of the internal orifice of the fistula.   His not
being able to find anything in such cases is no proof that the fistula
is incomplete ;  a bridle or sinuosities, or valvular folds, constitute so
many obstacles which are to be taken  into the account.  In certain
cases the  finger does more harm than good, and is not to  be  intro-
duced into the anus until afterwards.  Injections of tepid water may
be  made  trial  of for the purpose  of  having  more freedom in the
passages.   As  they  sometimes  come  back through the anus, it
has also been recommended  to make  use, for these  injections, of a
colored liquid,  or  milk, or ink, or water, for example, tinged  with
saffron or sunflower, in order that its presence may not be mistaken.
For the same reason such matters, if they were injected through the
rectum, are of a nature to come out through the fistula.
  The putting  in  of a  thread, as M.  Ruspoli recommends,  (Gaz.
Mid., 1835, p. 505,) would make the simple injection still less instruc-
tive than  the colored.  We might,  moreover, if it were necessary,
freely enlarge its  whole track  by introducing into it  tents of pre-
pared sponge,  or  gentian root,  or  anything similar.  When these
various essays  have  been followed by no results, we may  con-
sider that  the case in question is one of external blind fistula. What-
ever Foubert may say of it, the contrary cannot  be admitted  save
in the character of an exception.   The signs of an internal blind
fistula are not so numerous, but are less variable.  After pains or
symptoms of a  deep-seated phlegmon, a certain quantity of purulent
matters will be  observed to escape from the anus.  From that time
the  stools in coming out are found to be besmeared with them to a
certain extent, while during the interval the shirt becomes stained
with them.  Sometimes also the ulcer precedes the abscess or deep-
seated  inflammation at  the margin of the anus.  Then the acci-
dents develop themselves with more moderation at first and do not
increase  in intensity until afterwards.   The finger meets  with the
same peculiarities in the intestine as if there existed a complete fistula.
At the  exterior  we sometimes distinguish a simple painful induration,
and sometimes a violet or reddish colored spot with or without atten-
uation of the skin.   In pressing upon this point at the contour of the
anus, we empty the pouch of which it forms the bottom, and pus is
immediately effused into rectum.  Moreover we are  rarely called
upon to ascertain  the existence of an internal blind fistula, until it
has reached to  a very advanced stage ; for up to that time patients
pay no attention to them scarcely, and refer their difficulties to blind
piles, for which they do  not ask for any relief.   Urinary fistulas,
which show themselves in the neighborhood of the anus, are distin-
guished from the preceding, by the rose or particolored tubercle de-
pressed in the form of a pullet's rump, which almost constantly con-
ceals its orifice ; also by the species of fibrous cord which is prolonged
in the direction  towards the bladder or urethra, and by the fluidity,
color and  urinous odor which exudes from them ; also by the fact that
fluids do not usually escape from them except at the moment  when
there is a  desire to empty the bladder;  likewise  by the absence of
surrounding cavities,  and the  direction the  probe  takes, and  espe-
cially by the fact that this instrument cannot penetrate into'the rectum. 
FISTULAS.
793
                       § IV.—Prognosis.

  Fistulas at the anus in themselves are not dangerous.  Those which
have but one orifice, whether internal  or external,  blind fistulas in
fact, frequently terminate of themselves in a fortunate result, though
Boyer maintains the contrary ; it is even certain that complete, that
is, the true  stercoral  fistulas, sometimes disappear spontaneously.
I saw a remarkable example of this in an old soldier, who had been.
a long time a patient at the Hospital of Tours.  Another time, in a
woman,  I ascertained without the least  difficulty, by introducing a
probe, the presence of an anal fistula, at the beginning  of the year
1831.  Apprehending the attack of some pulmonary  affection, I sent
the patient into the country.   She came back two months afterwards
perfectly cured, and has  continued  to  remain so ever  since.   M.
Ribes  relates two cases which are not  less  conclusive.  Who does
not know, moreover, that these  fistulas  will  frequently close up
during the  space of a month or  year, then  reopen afterwards, and
finally get  perfectly  well; and  that a  certain number  of patients
have them without caring to  pay  any attention to them, and finally
find that they  cicatrize  without an  operation?    Such a result,
however, is one that is entirely exceptional.   In  the immense  ma-
jority of cases fistula in ano will not yield without the aid of art.
Whatever may be  the number of sinuses, we may obliterate them,
provided they have  not extended beyond the perineal aponeuroses
above, and that they are not kept  up by some  local disease.  If the fis-
tula has existed for a long period of years, and is accompanied by vast
cavities and by passages which  extend beyond the coccyx, sacrum
and glutaei muscles, laying bare  the latter, as I have  seen in several
instances; or if the levator ani has been attacked and the intestine is
extensively  dissected beyond the reach of the finger, it is rare  that
we succeed.  The most prudent course then, is to confine ourselves
to cleansing means and palliative treatment.   Like all wounds which
suppurate, a fistula at the  anus may give rise to the accidents of re-
sorption.  If fistula in ano ought to be  respected in pulmonary  pa-
tients, it is less because its cure aggravates the principal disease, than
from the impossibility of effecting  its cicatrization after having  ope-
rated upon it.  The contrary undoubtedly may happen, but it is only
by exception.  J. L. Petit, who was one of the  first to  investigate
this subject  profoundly, leaves no room for reply.   M. Morere, with
a view to subvert the principle which has been universally established
in our days, by relating the case of a patient, who, after being ope-
rated upon  for a complete  fistula, afterwards recovered from  his
phthisis, forgets that this patient  was not all phthisical.

                       § V.—Treatment.

  All the means employed in ulcers accompanied with separations of
the integuments, or  in sub-cutaneous  fistulous ulcers,  have  been
recommended for anal fistula.  We may find in Avicenna the waters,
unguents and balsams, recommended for this purpose  by the ancients.
The patients who were sent to the waters of Barrege and Bourbonne,
and the liqueurs and  pomades prescribed to Louis XIV., who him-
   vol. in.                     100 
794
NEW ELEMENTS  OF OPERATIVE SURGERY.
 self was affected with a fistula in ano,  prove that at the time of Dionis
 they were full as rich in resources in such cases as at the epoch of
 Galen and the Arabs.   Purmann succeeded with lime-water, calomel,
 alum  and orpiment.  Bourdonnets of lint, good diet and detergent
 injections were found sufficient by Pallas.  Injections of gum-ammo-
 niac were not less efficacious in the hands of Evers,  and it required
 all  the experiments undertaken in the case of Louis XIV., to reduce
 such pretensions to their just value.   Inasmuch as  this disease some-
 times  gets well without the slightest  assistance, it would not,  after
 all, be surprising if such remedies had obtained a certain number of
 cures, unquestionable examples of which are to be found in the col-
 lection of Bonet; but, as art possesses methods which are incompar-
 ably more advantageous, they have been for a long time abandoned.
   A.  Caustics.—Caustics, employed  at  the remotest period of an-
 tiquity, since they are already mentioned by Hippocrates, and that
 most of the Greek and Latin authors  also describe them, and which
 have  been eulogized so much by De Vigo, who especially praises
 vermilion, by means of which remedies  Lemoyne had, Dionis says,
 acquired a considerable fortune, and  which, according to Sabatier,
 other  charlatans still made use of at  Paris, even  with full as much
 profit  in the last century, are, however, at the  present day totally
 proscribed.  This does  not arise from their  being always ineffica-
 cious.   Tents impregnated with sublimate, litharge, asgyptiac, lapis
 infernalis, filings of copper,  arsenic,  or  precipitate and the actual
 cautery, which substances are still  made use of by MM. Dieffenbach
 (Kleinert's Repert., Sept., 1831, p.  81,) and Fingerhuth, (Encycl. des
 Sc. Aled., 1836, p. 205,) together with discs of minium and  a thou-
 sand other similar substances, are, on the contrary, of a nature calcu-
 lated to cure a certain number of fistulas, whether by modifying the
 surface of the ulcerous passage, or by destroying  the entire bridle
 which  separates  its two extremities ; but  the uncertainty of their
 action  and the disadvantage of destroying sound parts we would
 wish to preserve, do not allow of our having recourse to them except
 where  better methods are impracticable.   Simple fistulas, or such as
 have but little  depth, or where  there is great timidity and an ex-
 treme  repugnance  to anything having  the name  of an operation
 could alone, at the  present day, justify their employment in  certain
 cases.   The method of Sabatier, which consisted in introducing the
 roll or  tent impregnated with the caustics  only in  the direction of the
 bridle  to be destroyed that is, to the  intestine, would  then deserve
 the preference if our object was  to effect  a destruction of parts  and
 not  to  limit ourselves to a modification of the entire morbid surface
 by means of chemical cauterization.
  B Ligature.-The same remark nearly applies to  the ligature
 which, according to one of  the books attributed to Hippocrates wn,
 formerly constructed of five strands of thread surrounded with how"
hair, and which was passed  from the fistula into  the intestine  bv
means  of a probe, in the same way as with caustics and injections
At  the present day  it is but rarely made  use  of  At  tU t'      r
Celsus  they used a kind of  packthread  besmeared with someTscha
rotic substance.  Avicenna preferred twisted hairs or hog's bristles"
G. de Sahcet recommends, according to  Sprengel, that we  should 
FISTULAS.
795
employ a small cord having knots upon it, for the purpose of cutting
through  the parts; while Guillemeau, who was an imitator of Pare,
passed it into the rectum by the fistula and through a canula with a
needle having  a double cutting edge.  Notwithstanding the  argu-
ments of Foubert, who  substituted a  leaden wire for  the ordinary
thread, and who, for the purpose of introducing it, contrived a probe
in the form of a larding  pin ; of Kamper who  returned  to the liga-
tures of linen or silk thread; of J. F. Bousquet, who  recommends
that the  leaden wire should be surrounded with lint and  introduced
by means of a needle; of Desault, who employed a directing sound,
and afterwards a canula, like Pare, and then a leaden wire which he
seized in the intestine with his finger or with  his gorget forceps, in
order  to  bring its  extremity through  the anus  and  to fasten  it by
means of a knot-tightener;  of Flajani, who  makes use only  of  a
waxed hempen thread;  and of the greater part of timid surgeons,—
the apolonosis counts scarcely any more partisans  among the  prac-
titioners  of the present day.  The advantages which are  ascribed to
it by its defenders, and which are more apparent than real, are coun-
terbalanced by  numerous  inconveniences.   Its  action  is extremely
slow.  The strangulation which it exercises causes sometimes a good
deal of pain and nervous contractions, which are necessarily alarm-
ing.  Complicated,  multiple, and  deep-seated fistulas  would yield
to it but rarely, while in the most simple  cases  it is far from being
always found to answer.  However, if any one should still be disposed
to make  trial of it, it would be a matter almost of indifference whe-
ther we made use of a  strong cord of waxed  thread or of silk, or a
leaden wire, or one  of  fine silver, which,  in the first case, is to be
passed through the fistula by means of a flexible probe ;  and  in the
second case,  along a grooved sound, or  through the interior of  a
canula, and then brought to the  outside by means of the left  fore-
finger, which proceeds  to search for it in the intestine in order to
form a noose with it.  The extremities are afterwards to be enclosed
in the bullet knot-tightener of Riolan, that of Girauld,  or what is
better, M. Mayor's, or in the instrument of Desault, or  twisted upon
themselves if they are of a metallic nature.  By taking the precau-
tion to tighten them  in proportion as the tissues yield, that is to say,
every day or every two or  three days, according as a greater or less
degree of constriction is produced, we succeed in cutting through
the entire bridle in the space of from twenty to thirty or forty days;
so that at the moment  when the ligature falls the fistula is usually
found cicatrized.   But how often are we obliged to remove it  before
it is time, in consequence of the pains  which it causes, the tardiness
of its operation, and the utter  inability of the patients to endure it!
In 1824 M. Bougon made trial of it at the hospital of Perfectionne-
ment, on a courageous  adult of excellent constitution.  The patient
kept it in for three weeks, complaining of  more and more acute suf-
fering every time it became necessary to increase the constriction.
At this period the bridle, though it was of small length, was not half
cut through, and as the  pains went on increasing, it was deemed ad-
visable to proceed to excision, which was attended with prompt suc-
cess.   When properly considered, the ligature, from  its being appli-
cable only to superficial and simple fistulas, ought to be laid aside. 
796
NEW ELEMENTS OF OPERATIVE SURGERY.
 and with so much the less regret because the methods which we then
 have as a substitute for it are generally attended with but little pain,
 and are applied with as much facility as certainty.
   C. Excentric compression.—Surgeons, however, have not all yet
 abandoned the idea of curing anal fistula without a  bloody operation.
 In these latter times there has been suggested a remedy which has the
 appearance of being even very ingenious, and the object of which is
 to dry up the ulcer  by closing its internal  orifice.  The suggestion,
 which belongs I believe to M.^Bermond, also occurred  to M. Colombe.
 The first considers that his  double canula with sheaths, applied  in
 the manner described  farther back, (see hemorrhoids,) would  per-
 fectly carry out the indication, and  the second  alleges  that he has
 succeeded in  keeping  up in the anus a hollow ebony cylinder, re-
 tained outside by means of ribbons.   It  is a method which may be
 made trial of, but which experience has not  yet sanctioned, and from
 which we must not anticipate too great a degree of  benefit.  In a pa-
 tient in whom M. Colombe himself employed it, the mucous membrane
 of the rectum  was  invaginated into the upper opening of the com-
 pressing body, and occasioned acute pains.  M. Piedagnel alleges
 that he has attained  the success desired by  fixing into the rectum  a
 small sac filled  with lint, in the same way as for the purpose of ar-
 resting a  hemorrhage  there.  M. Montain, (Therap.  Aled.  Chir.,
 p. 85,) even asserts that he has cured a number of fistulas at  the anus
 by means of a compressing instrument, which had its point d'appui on
 the hip, and which was aided by cauterization.  But all these modes
 appear to  me  of very  doubtful efficacy.  There is  nothing, there-
 fore, after strict analysis, but the  cutting instrument, which can tri-
umph with certainty over fistula in ano, and cure every  form of it.
  D.  Incision.—The ancients, notwithstanding their predilection for
 caustics and the ligature, knew also  however, that  the best  remedy
 for fistula in ano was incision.  Hippocrates mentions this in express
terms, and the syringotome, a kind of sickle-shaped bistoury, em-
ployed in  the  time of Galen,  proves this satisfactorily.   Leonidas,
 (Peyrilhe, Hist, de la Chir., p. 442,) performed this operation with
 an instrument which terminated in a long flexible probe, and which
was introduced through the fistula, and brought out through the intes-
tine, in such manner as  to  divide the bridle with one cut.  In the
 medieval epoch H. de  Lucques first introduced a ligature, and then
 made use of it  as  a sound or probe to stretch the  parts before in-
 cising  them.  Guy de  Chauliac, who was  always alarmed at the
idea of hemorrhage, preferred a grooved sound on which he guided
 a bistoury heated to a white heat.   F. ab Aquapendente, after hav-
ing dilated the fistula  with his speculum, merely used for making
 the incision, a  blunt-pointed bistoury slightly concave, together with
 a sound.   Others, as  Spigel  for example,  proposed to sheath the
 syringotome in a silver, curved, blunt-pointed canula, which pen-
 etrating the first into the  rectum was  to be withdrawn from it by
 the finger, leaving a thread at the extremity of the bistoury  in order
 to draw that at the same time by its point and handle, and  to divide
 the fistula with one cut.  It was Marchettis who suggested  the idea
 of introducing a gorget into the anus, for receiving the  point of the
 cutting instrument or of the sounds.  Wisemann got along very well 
FISTULAS.                         797
 without them, and made use of a scissors in place of the syringotome,
 which, however, did not prevent Felix from reviving the bistoury of
 Leonidas, which he modified by covering it with a coating in order to
 render its introduction less painful, and which instrument subsequently
 received the title of royal from the operation which  was performed
 with it upon Louis  XIV.  J. L. Petit showed, that an ordinary bistou-
 ry slightly concave, and guided upon a grooved sound, was full as good
 as the instruments which had been extolled up to that period; and
 Runge gave as  much security as possible to this process, by advising,
 like Marchettis, the use of a gorget, a gorget which Percy (Mem. de
 VAcad. Roy. de Med., t. II., p. 1,)  prefers should be of wood, rather
 than metal, and  by using also a grooved sound, which two instruments
 were introduced, one into the intestine and one through the fistula, in
 such manner, that by means of a straight long bistoury with a thick
 point, destined to glide upon the sound, we could cut through all  the
 parts comprised between them.   Z.  Platner considered that he
 could make an improvement in the mode of incision, by recommend-
 ing that we should  accomplish it  by  means  of a concealed bis-
 toury,  which others  commonly employed with the gorget.   Pott,
 with a  view of simplifying it still  further, required nothing more
 than his curved  blunt-pointed bistoury, which B. Bell replaced by a
 narrow bistoury terminated like the  beak of a  sound.   The instru-
 ment of Pott was  almost  immediately  modified by Savigny, who
 fixed upon one of its  sides a pointed blade, which could be thrust out
 or drawn in at pleasure, and by T. Whately, who made  its cutting
 edge  movable,  and  arranged  it  in such  manner as not  to with-
 draw it until after having  introduced the probe point  of its blade
 into  the rectum.   In  our  times some  persons, however,  have  re-
 vived this bistoury,  the point of which Dorsey  elongates into a
 cone, while A. Dubois makes the instrument advance upon a flexible
 grooved sound,  which has been previously brought  out of the anus
 through the intestine  by means  of the  finger.   The ancient probe
 bistoury of Leonidas  revived by H. Bass, and afterwards by Brunei,
 is the instrument adopted by M. Larrey.  In the way this last surgeon
 has modified it, it is no other than  an ordinary  straight bistoury, ter-
 minated by  a Jong flexible blunt probe, which is pushed througn  the
 fistula and brought  out by the anus, and which, requiring no director,
 divides with a single  stroke the whole thickness of the  bridle.   Fi-
 nally, M. Charriere has constructed one, the back of which is grooved
 in such manner, that it glides as well on  a cylindrical stem as upon
 a grooved sound, so that  the exploring  probe  which is ordinarily
 used  becomes its conductor, and has no need of being replaced  by
 the sound.   Without denying the successful results ascribed to  each
 of their numerous processes, we may at least maintain that there is
 nothing of any real utility to be preserved  out of all this arsenal  of
 instruments, but   the wooden gorget of Percy, the  grooved sound,
 the straight bistoury, and the bistoury of Pott, or that of M. Larrey,
 as in fact has been done by the moderns.
  E.  Excision.—Nor has the mode  of performing excision always
 been the same.   According to Celsus, we are to make an incision on
each  side of the fistula, he  says, and then to  remove all the parts
which are thus circumscribed.  Paul of Egina  had recoursa to the 
798          NEW ELEMENTS OF OPERATIVE SURGERY.
 ordinary syringotome, forceps, and bistoury.'   Some excised only all
 the movable wall  of the fistula, aftei having embraced it in a noose
 of thread or raised it up with a forceps or sound, and to make the
 excision made use of either the straight or concave bistoury, or curv-
 ed scissors, as was still preferred by G. Heuermann.  Others were not
 satisfied until after having excised  the whole fistula, either with one
 cut or by excising its two walls in succession.  There are those who,
 after the wall of the fistula was destroyed, confined themselves to
 pure and simple scarifications  of the callosities.  At the present day,
 those who, like Boyer, adopt excision, begin  by incising the fistula,
 and  afterwards confine themselves to  the removal of  the divided
 flaps, (des  teguments decolles,) which  they seize  with the forceps
 and excise with the bistoury.
   F.  The manual of the operations for fistula.—A purgative ad-
 ministered the evening before, if  the state of the  digestive  organs
 allows of it, is required in order to prevent the necessity of too soon
 going  to stool.  " An injection,"  says Dionis, " ought  in fact to be
 given two hours before, in order that during  the operatio*n the sur-
 geon may not incur the risk of having his face besmeared with ster-
 coral matters."
   I.  The articles required consist of the particular kind of bistoury
 which  is preferred, several ordinary bistouries, a pair of strong  dis-
 secting forceps, a grooved  silver sound, and one of steel, without a
 cul de  sac, a gorget of ebony or box-wood, straight scissors, and those
 that are curved flatwise, a number of cauteries, needles, and ligature
 threads, a long meche and meche-holder, tampons, and the hemosta-
 tic means elsewhere mentioned, (see Excision of Hemorrhoids,) small
 balls of lint, three or four plumasseaux, long compresses, square com-
 presses doubled twice or tour times, and a T bandage doubled.
   II. The patient is laid  upon the right  side,  when the  fistula is on
 the right, and on the contrary, on his left side when it  is on the left,
 in front, or behind, and doubles himself up, with  his head lowered
 and his belly supported upon a transverse  piece, while  he stretches
 out the limb which is below, and flexes the  other.  An assistant situ-
 ated  in front of him  prevents him  from raising up his head, and
 watches his arms.   The pelvis  and  the flexed leg are kept immova-
 ble by a second assistant.  A third  placed behind  him, is charged
 with separating the buttocks, and of holding the gorget at the proper
 moment.  Finally, there will be required a fourth, and even a fifth
to hold the other leg,  to stretch the tissues, and  to  hand the instru-
 ments or cleanse the wound.
   Ill   Before proceeding farther, we search for the two  openings of
the fistula.   The discovery of the  one  outside cannot be  attended
with any great difficulty   The stercoral humidities,  or the  pus
which  escape from it, suffice, in the  absence  of a  wound to point
out its  seat, even though it should be at the centre of a hemorrhoidal
tubercle, or in the bottom of some tegumentary  duplicatures  It is
not always the same with the internal opening.  This  last presents
itself quite frequently at the middle of a small induration or pullet's
 rump, very readily distinguishable by the finger  introduced into  the
 rectum, or it appears under the form of quite a large ulcer, which mav
 be recognized with still greater facility.   Frequently it is not found 
FISTULAS.
799
because  we look for it too  high up.   It is sometimes so near  the
skin externally, that it  requires attention, in order that we may not
be deceived.  It is only after having carefully explored all the stran-
gulated or straight portion of the intestine, that we should proceed to
examine if it is not situated  higher up.  A flexible probe, moreover,
will remove every doubt.  We  introduce  it  with the right  hand
through the cutaneous orifice, and with caution, in the direction of
the fistula, and allow  it to follow without  effort  the  various tortu-
osities, so that its head will soon present itself to the finger of the left
hand, which is waiting for it in the rectum.  When there  is but one
external opening, this  probe in general  penetrates with a sufficient
degree of facility, unless the  fistula should  turn round at  too sharp
angles in the course of its progress.   When there are several passa-
ges, on  the contrary,  or numerous openings around the anus, the
search sometimes is attended with a great deal  of difficulty.   We
then introduce the probe into each of  them  in succession, proceeding
in the manner just described.   The failure  of such explorations  does
not authorize us to conclude that there is no opening in the intestine.
There are too many circumstances  which  may conceal it from the
view of  the operator.  If some milk were  retained above the anus,
it would prove, if it issued  through the outer orifice, that an  inner
one existed in the  same way that if pushed through the outer the
milk should be seen to return through the anus.  Any other  mild
fluid of a strong color would serve the same purpose.  It happens in
other cases that the exploring instrument is found no longer separated
from the forefinger except by a thin pellicle, like a sheet of paper, and
yet notwithstanding it  cannot be made to present itself naked in the
intestine.  It will glide with freedom  in every direction without the
slightest  trouble.  We perceive that the mucous membrane  is atten-
uated and separated, and nevertheless still recognize that the end of
the  probe is  outside  the gut.  Does an opening exist on  some
other point ? or is it not rather an external blind fistula 1  it is impos-
sible to say.  A decisive step however must be  taken.  This  state
of things, which formerly was found  very embarrassing, and which
is  still one of  the most disagreeable  for those  surgeons who do not
consider it proper to operate until after having explored the  fistulous
passage through both openings, does not, in the opinion of M. Roux,
require so many precautions.  This surgeon, in fact, affirms that the
internal orifice of the fistula to be  divided, is far from deserving the
importance which is generally attached to it.  Whether it exists or
not, the remedy is the  same.   The decollement of the rectum is suf-
ficient to justify the operation.   Those minute researches, which oc-
cupied so much of the attention of the members of the Academy of
Surgery,  appear to  him to  be almost superfluous.  As  for myself,
who, like M.  Jacquier, (communicated by  the author, 1839,)  have
seen the  disease persist in patients operated upon after the precepts
of M. Roux, and who,  on the other hand, am aware of the successes
obtained from this method by M. Begin, I am of opinion, that without
neglecting those means required to ascertain if the ulcer  opens into
the intestine, we  should nevertheless  operate, when we  do not find
it, if the  disease should continue to  persist for  some months,  and
that the rectum bas undergone decollement to a certain extent.  If 
800
NEW ELEMENTS OF OPERATIVE  SURGERY.
 however the opening shall have  been found, and is not situated very
 high up, the silver sound is immediately to be substituted for the probe.
 We proceed with the forefinger  to search for it in the rectum, seize
 its point, and, after depressing and curving it  a  little, bring it out by
 the anus, while at the same time the surgeon continues to urge it along
 the fistula with his right hand.  A simple strait  bistoury, such as that
 employed by M. Richerand, M. Ribes, and Sabatier, and as is recom-
 mended by  Dupuytren. and which I have  several times myself made
 use of, or Pott's curved bistoury, or Dorsey's, with a conical point, or
 the slightly concave bistoury of J. L. Petit, being  then guided upon the
 groove of a sound, the extremity of which is steadied by an assistant,
 divides through the whole bridle  with a single cut, making the opera-
 tion one of extreme simplicity.
  IV.  When the fistula is higher up, or the decollement has extended
 very far, it  is better to  imitate Boyer and M. Roux, by making use
 of *a steel director with an extremity somewhat  pointed.  It  is intro-
 duced  as high as to the upper part of the fistula.  A gorget is then
 to be substituted for the finger, which last in the  rectum had followed
 all the  movements of the sound, and now presents to it the gutter of
 the gorget.   The director is to be pushed against the gorget in such
 manner as to pierce through  the intestine.  By moving them  back-
 wards  and forwards so that  they rub against each other, we satisfy
 ourselves that they are in actual  contact.  At this stage the assistant
 seizes the handle of the gorget, fixes it, and reverses it a little to the out-
 side, as if for the purpose of vibrating it.   The surgeon, with his left
 hand, acts in the same manner on the plate of the director; seizes a bis-
 toury with a strong point with his right hand; fixes its point  into the
conducting groove ; pushes it quickly up to the gorget; and withdraws
it by elevating his  wrist ana without allowing it  to  abandon the
 point d'appui which he has given to it.   For fear the whole of the
 bridle may not  have been divided, the bistoury is to be reintroduced
 a second and even a  third time upon the director; after which, in
order  to  be  certain that we have left  nothing,  we  withdraw the
two auxiliary instruments as  if they were a single  instrument, and
 without separating them.  Should there remain a cul de sac above,
 we  should immediately proceed to lay it open by dividing, by means
 of the  scissors  guided upon  the finger, the abnormal valve which
 forms it.  The cutting edge  of  the  bistourv  turned to the  outside,
 is then to be directed upon the bottom of the wound, which  latter it
 incises  or scarifies to a moderate extent throughout its whole length,
 and afterwards prolongs  it, at the expense of the skin, to the distance
 of about half an inch or an inch upon the buttock.   However little
 decollement or attenuation of the integuments may have taken place,
 they are to be incised by a crucial incision or a T incision reversed,
 after which  each of the flaps  is to be seized with a forceps  and cut
 off at their base from their free surface to the  wound, by means of a
 bistoury   Without this precaution the suppuration would be intermi-
 nable and a  cure rendered very uncertain.  The pain that it causes
 and the time that it requires, are nothing in proportion to the advan-
 tages that result from it.  Prudence does not permit us to dispense
 with it except  in the cases of those fistulas which are wholly of a
 simple  character.  What we  have done on the first fistula we repeat 
FISTULAS.
801
on the others, in order that we may reunite them at the wound of the
rectum.  All the tegumentary flaps which are thus formed are also
to be  excised, however little they may be altered or attenuated.
The same bistoury, or the probe-pointed one, and always to be con-
ducted upon the finger, is to be made to act in the last place upon
the different  bridles and valves which are met with at the bottom of
the openings or of the wound, in order, before we terminate, that we
may regularize, as perfectly as  possible, the whole interior  of the
bleeding surface, after which the operation is finished.
  G. The dressing is the same as for fissure at the  anus, except that
the meche should be larger.  It is important, after having intro-
duced it, to separate a bundle of fibres from it to place between the
lips  of the wound,  beyond  which latter  it should pass up  to the
distance of an  inch or two.   A sufficient quantity of coarse lint and
plumasseaux laid over this fill up the margin of the anus.  The whole
is then to be covered over with two or three square compresses and
afterwards by as many long compresses, which are to have some
degree of width.   The two heads of the T bandage previously fixed
around the belly, then brought down over these different portions of
dressing, passed between the thighs, and then crossed and brought in
front,  one  to the right and the other to the  left, and afterwards
knotted or  fastened with pins upon the hypogastric circular, complete
the dressing.
  H. Accidents.—Hemorrhage,  should it occur, is to be treated in
the  same way as after excision of  hemorrhoidal  tumorsr   If the
artery which bleeds can be seen, it is to be surrounded with a thread,
unless we should prefer torsion.   In the contrary case we introduce
the pulp  of the finger into the bottom of the wound, in order to com-
press in  succession  all  the  differents points of it.  As soon as  we
arrive by chance upon the vessel, the  blood ceases  to flow.  This is
the point consequently upon which we must apply the small balls of
lint, charged  or not with hemostatic  powders or liquids.   The  meche
and  other  portions  of  dressing  are afterwards adjusted  as  above
described.   Should we  not succeed, and that the tamponing also of
the whole  bleeding  surface does not  prove sufficient, we have no
other resource  than  to choose between the actual  cautery, Levret's
bladder,  Blegny's gizzard, the tampons of J.  L.  Petit, adopted by
Boyer, or the apparatus of M. Bermond; but it rarely happens  that
we are reduced to this necessity, and so much  the less so inasmuch
as the hemorrhage, which sometimes follows the operation for  fistula,
is useful rather than injurious, and that in almost in  all cases it ceases
spontaneously before it has become alarming.
  I.  Remarks.—The exclusive partisans of incision do not  always
proceed  precisely in the  manner which has been described.  The
decollement  (denudation)  of the rectum is not, in  their opinion, a
reason for  prolonging its incision above the fistula.   They maintain
that  after the operation  the intestinal wall will attach itself and soon
become agglutinated on its outside to  the suppurating surface;  that
so also its cutaneous flaps and indurations do not fail tore-agglutinate
or disappear, as soon as the  bottom of the fistula  has become con-
tinuous with the anus, without any interposing impediment, and con-
sists of nothing more than a  mere notch or gutter in the intestine;
  vol.  in.                    101 
802          NEW ELEMENTS  OF OPERATIVE SURGERY.
 that we in this manner abridge the length of the operation, and much
 of the sufferings of the patient, and also the continuance of the sup-
 puration and the period of the cure: that we have less reason  to
 apprehend  hemorrhage  and fever, and that  less deformity  results
 from the operation; finally, that the important point is to interrupt
 the continuity of the sphincter, which, by retaining the faecal matters,
 obliges them to penetrate  in part into  the fistulous  passages.   The
 objections to be made  against this reasoning are, that if the denuded
 and attenuated parts may,  in fact,  ultimately become re-agglutinated
 after a simple incision, in a considerable number of patients, so is it
 not uncommon  to find the contrary take  place.   Moreover, how
 could it  be otherwise ?  We see here nothing more than is remarked
 every day, on every other  region of the body.  There is nobody at
 the present time who  has  any doubt, that the excision of the livid
 and attenuated flaps which cover the bottom of a great number of
 interminable cutaneous ulcers is the best remedy that can be opposed
 to  them.  The section of the sphincter  does not always take place;
 moreover, it is not this muscle, but in fact, the fibro-muscular circle
 situated  above it which forms the  most  contracted part of the anus.
 After all, what have we to  fear?  A loss of substance in the midst of
 such soft parts is soon  repaired.  The pain is less acute than is gene-
 rally supposed.   By the very fact  itself that the tissues are attenu-
 ated  and,* as it were, dissected, they cannot contain vessels of large
 calibre.  Difficulties there are none, for those who know how to handle
 the bistoury.  In a few seconds  all the  flaps have been  seized  and
 extirpated.  The patient, resigned  to the operation, prefers suffering
 a little more, in order to have all the chances possible of being cured
 with certainty and rapidity.  On the other hand, we do not perform
 this excision except in fistulas that  are accompanied with a very
 marked degree of decollement.  The division, in fine, scarcely falls
 upon anything else than the skin, and the whole is limited to a pure
 and simple incision when the passage to be destroyed is not surrounded
 by  any disorganization.  In a word, the indication to be fulfilled in
 these cases presents itself under two points of view: first, to dry up
 the source of the fistula by incising the rectum ; and secondly, to place
 the wound afterwards under such conditions that its cicatrization may
 be  accomplished with facility.
  I. Those fistulas which open upon the anterior wall of the intestine
 exact somewhat  more precaution  than the others.  Their excision
 should not be attempted without some very evident necessitv  The bis-
 toury introduced  into the bottom of these for the purpose'of scarify-
 ing them, could reach too quickly into the bladder and peritoneal cul
de sac, or upon  the prostate, to  make it allowable for us to expose
ourselves to this risk.   When they are very high up, no  matter in
what direction, the operation is at  the same time more difficult  and
more dangerous; not  that  we have seriously to fear wounding the
peritoneum, even though the fistula should be as high  up as the sa-
crum  Practitioners who have pointed out this danger, had doubtless
forgotten that the morbid  opening perforates only■ through the nVn-
cous and muscular membrane, without implicating the se?ous tunic •
that the pus is effused into the cellular tissu? and n?t into /ne cavity of
the  abdomen;  that if the peritoneum was ulcerated  there would be 
FISTULAS.
803
an effusion into the belly, and a disease almost inevitably fatal, or at
least, one too serious to think of an operation ;  and that the bistoury,
from its not leaving  the groove of the director which has been se-
lected,  cannot, scarcely  by any possibility, reach the  peritoneum,
even though the surgeon  had that intention, and that the lesion of this
membrane is not, if all things are well considered,  more to be dreaded
above than  below, or  in front or behind the intestine.   The danger
arises from  the fact  that we may incise beyond  the lower limits of
the ischio-rectal aponeurosis, or, in truth, of the internal  border of
the pelvic aponeurosis, and which would expose  to the risk of puru-
lent filtrations between those two layers in the first place, and after-
wards into the pelvis between the peritoneum and the fascia pelvica.
  II. What precedes is to be understood only  of those fistulas in the
anus which are kept up exclusively by some local affection, or by
the destruction of the cellular tissue, or the perforation of the rectum.
Those   which depend  upon a caries, a  necrosis,  or any alteration
whatever of the ischium,  coccyx, sacrum, or vertebras, and the source
of which lies in a deep-seated suppuration in  the abdomen or chest,
are purely symptomatic,  and the cure of which cannot be thought of
until their cause has  been  removed.  When they are  complicated
with syphilis  or any morbid diathesis, we must at least, should we
decide upon operating, subject the patient at the same time to the
particular or general  treatment  required  by the nature  of the affec-
tion.  It is from having proceeded in a contrary  manner that certain
operators have found the wound continue open to an indefinite pe-
riod, and the  suppuration resist every attempt  to dry it up,  though
there may have been no circumstance nor any anatomical alteration
which could interfere with its cicatrization.
  III. Experience proscribes  the  performance  of the  operation in
consumptive patients:  1st, because  in most instances  the fistula
moderates the progress of the pulmonary disease; 2d,  because it is
usually  caused by the ulceration of  one of the thousand tubercles
with which all the organs are then cribbled; 3d, because the wound
rarely heals up,  but suppurates abundantly and reacts in an injurious
manner upon  the ensemble of the organism; and 4th, because,  if by
chance  it closes up, it is remarked that the pulmonary affection, which
was momentarily  suspended, rarely fails to become thereby aggra-
vated.   This  however is not an argument  for  creating a complete
artificial fistula in the  anus  of tuberculous patients, by introducing
into the rectum  a long darde inclosed in a large canula, from whence
it may  escape when we  wish, in such manner as  to traverse the in-
testine  from within  outwards and from above downwards, so  as to
come out at the margin  of  the anus, while dragging after it a seton
destined to remain in the wound, as has been proposed, and in one
instance practised by  M. Heurteloup, at La Charite.  Nothing more
can be  hoped for from a resource  of this kind than from a seton at
the nape or a blister on the  arm.   I am of opinion even that in cer-
tain cases, a fistula at the anus may co-operate from the pus which it
furnishes to the general circulation, in the production of tubercles, and
in creating  a pulmonary  diathesis,  instead of being a remedy  for it.
  IV.  The  little frequency of internal blind fistulas is owing to two
causes: 1st, because they  are speedily transformed  into complete 
804
NEW ELEMENTS  OF OPERATIVE SURGERY.
 fistulas; and 2d, because in the contrary case the ulceration is suffi-
 ciently moderate to allow of their spontaneous cure.   This is what
 I saw happen in a patient in whom I was obliged to lay open, through
 the interior of the rectum, an extremely painful abscess, which it was
 impossible to  recognize  externallv, and which made a decided  pro-
 jection into the intestine, and from which there escaped more than a
 tumbler full of pus.  Moreover, to operate upon fistulas of this kind,
 we endeavor to transform them into complete fistulas,  either by re-
 taining the pus in their interior by means of a tampon introduced over
 their opening, or by a  stem  curved into a hook and passed through
 the anus, with its short branch lodged in the ulcer.  These resources
 enable us to ascertain the point on the  perineum which corresponds
 with the fistula, and  thus to lay it open with a cut  of the bistoury.
 Moreover, when the intestinal orifice has once been  discovered, it is
 not necessary to have recourse to so many means  of exploration.
 The  bistoury introduced flatwise  upon  the finger and having a small
 ball of wax on its point, would succeed  perfectly well, by incising
 the rectal wall  of the fistula from above downwards and from within
 outwards, in the same way as if it were an ordinary abscess, and in
 such  manner as to divide through  the sphincter, should that be deem-
 ed advisable.
  V.  As to the question whether  it would be proper to operate for
 the fistula with  the same cut  which lays open the stercoral abscesses,
 as was recommended by Faget, or whether it would not be preferable
 to make a puncture only at first and to operate subsequently, as Fou-
 bert has advised, opinions at the present day have unanimously deter-
 mined in favor of this last mentioned author: 1st, because the intro-
 duction of the finger or gorget would then occasion too much pain;
 2d, because, from our  not being able to  ascertain where the open-
 ing is nor to what point the decollement has extended, it would be-
 come necessary in most cases to repeat the operation after the expi-
 ration of a certain period of time; and 3d,  because many  of these
 abscesses, when they are once laid open heal up without any other
 operation, which Foubert had already noticed, as is shown also by sev-
 eral cases which I have published, and other instances of which I have
 since met with.  To operate upon multiple fistulas at several times, and
 at intervals of several days, as was done by Fichet de Flechv, (Diet
 de Mid., 2d ed., t. III., p. 38,) and as others have since proposed, would
 not be advisable except it were impossible to find their various orifices
 on the first day.  I have elsewhere, (France Aledicale, t. I., pp. 57,
 61, 73, 78,) mentioned  the special circumstances connected  with fis-
 tula in ano in women.
  VI.  The subsequent dressings is a point of great importance after
 he operation for fistula in ano.  Almost all French surgeons maintain
 hat a large meche should be constantly kept up in the rectum, or
that there should be at  least always a portion of it kept between the
hps of the wound  Unless that were  done  the  cicatrization, they
say, would  first take place upon the mucous  membrane, and the fis-
 tula be thereby reproduced.   The cure cannot be complete and per-
manent unless  it proceeds from the bottom to  the  borders of the
wound  A  patient who was doing very well, was temporarily left
 by Sabatier, who ascertained at the end of three weeks, that the fis 
CANCERS OF THE ANUS.
805
 tula had formed again, when it was found that the assistant to whom
 ne had entrusted the care of the meche, had  not employed it in  a
 proper manner.  The  incision was then repeated.   Each dressing
 was performed by Sabatier  himself with the greatest care, and this
 time the disease entirely disappeared.  Boyer  holds precisely the
 same language, and relates facts that are exactly similar.   Pouteau,
 nevertheless, who  contended zealously against this doctrine, affirms
 while he supports himself also upon the  facts which experience has
 furnished, that the meche is not only useless but even injurious, from
 the irritation and compression which it causes upon the bleeding sur-
 face, which latter, according to him, requires no other treatment than
 that of simple wounds, which we wish to take on suppuration.  In
 England  the principles of Pouteau are universally adopted.  A strip
 of fine linen or some strands of lint is all  that is allowed to be placed
 between the borders of the wound, and M. S. Cooper among others,
 is unable to comprehend  what he denominates the French practice.
 On this point, as on so many others,  we may, I think, readily furnish
 an explanation.  It is not probable that  the same differences in this
 respect exist in practice  as is found in books.  The object is to pre-
 vent the  reagglutination of the  lips of  the wound before we have
 modified its  bottom, and  forced it, in fine, to become cicatrized by
 degrees, from its sides towards its deepest portions.  To  effect  this,
 what have we to do ?  A slender meche would not always answer,
 because in most cases it would be found to be expelled by the wound
 of the anus itself.   On the other hand the large cylinder of thread
 which is  used among us is not indispensable, for we  may with a
 meche, which is more supple and smaller, keep the solution of conti-
 nuity sufficiently open.   It has moreover the positive inconvenience
 when it is persisted in for too long a  time, of flattening down the cel-
 lular granulations,  whose  development also it interferes with.   Rea-
 soning and experience concur in showing  that a meche of medium
 volume is advantageous during the ten or fifteen first days, that we
 may afterwards without any disadvantage make it gradually smaller
 and smaller, and that it is advisable to dress flatwise with soft lint as
 soon as the traumatic surface is of a vermilion color and  appears to
 be disposed to cicatrize.   As to the rest,  this wound  is to be treated
 like any other, which remark  applies  also to  the various  accidents
 local  or general which may take place  during the  progress of the
 cure.

              Article IX.—Cancers of the Anus.

   No part is more liable to lardaceous, and even cancerous degene-
 rescences, than the  termination of the rectum.   They present them-
 selves here sometimes under the form of  tumors, which are more or
 less projecting, and with a base of greater or less  width;  sometimes
 with the appearances of  a perforated diaphragm, especially when it
 is  the  valve described by M.  Houston, (Dublin  Hosp. Reports,
 p.  162,) which constitutes their seat; and at other times, under the
aspect  of plates, which are more  or  less  extensive, either  in height,
thickness, or breadth, and which sometimes occupy the  entire con-
tour of the  organ.  When topical applications,  debridements,  and 
806
NEW elements of operative surgery.
  compression, have proved insufficient, and that the disease continues
  to progress, we have to  apprehend, whether it be cancerous or not,
  that it will terminate fatally, unless we resist it by more  efficacious
  remedies.
                               §1.

   Extirpation is a last refuge  towards which the mind then natu-
  rally turns.   This suggestion has  occurred to  various persons who
  have ultimately recoiled- from the operation, or become alarmed with
  the difficulties attending  its performance.   Desault does not con-
  sider extirpation admissible, but  for those tumors which are of a bad
  character, perfectly defined and  movable, and the  various prolonga-
  tions of which may be reached without any difficulty.   Boyer is of
  the  same opinion.  All the school of the ancient Academy of Surgery
  adopted this principle, which originated with Morgagni.   The sur-
 geon who ventured to make trial of it  at the time of Morgagni, was
 unable to finish the operation;  and Beclard, who, according  to M.
 Paris, maintained in his course of operative  surgery at La Pitie, in
 1822 and 1823, that at the improved state to which surgery had then
 arrived, schirrous  indurations of the rectum ought no longer to be
 considered necessarily mortal, and that we  ought  to remove the al-
 tered parts while adopting all the precautions required by the  prox-
 imity of the bladder, and numerous vessels which surround the lower
 extremity of the intestine, had not an opportunity of putting this pro-
 cess into practice.   It was Faget who appears to have been the first
 who  successfully performed this operation, viz., on 9th June,  1739,
 in presence of Boudou and his brother.  He excised about an  inch
 and  a half of the whole circumference of the rectum.  What chiefly
 struck his attention was, that the stools  could be made with the new
 anus in the same way as they had  been made before the operation,
 although almost the entire  sphincter or plane of circular fibres which
 surround the anal opening  had been excised.   After having endeav-
 ored to explain the formation of  a new constricting muscle, and the
 mode by which M. Gele, his patient, was enabled to retain both solid
 and liquid matters, and even air,  Faget came to  the conclusion that
 extirpation of the anus, even at a very considerable height, was a
 practicable operation.  M. Lisfranc has furnished the proof of this
 His first patient, who was operated upon on the 13th of Feb., 1826
 found himself,  it is said, completely restored on the  13th of April fol-
 lowing.  He obtained  a similar  success in the month of January,
 1828, in a woman, and afterwards a third, in another woman opera-
 ted upon the 15th of July, and cured the 28th of October of the same
 year.  In a fourth patient  the cure  remained doubtful, and the fifth
 died  on the 10th of March, 1829, 4 days after the operation, from a
 suppuration in the  pelvis, and probably with a  phlebitis.  A sixth
 who  was a man 72 years of age, succumbed on the following  day!
but. the body could not be examined.  His seventh patient died at the
expiration of 25 days and also had pus in the pelvis and veins.   But
the thesis of M. Pinault, which contains all these facts, also gives two
instances  of cure;  by  which it would appear that ,n tn tL ™  ft
of August, 1829, M. lasfranc, out of nine $%£?£l£Z^
 counted five successful results, one of partial success, and three deaths 
CANCERS OF  THE ANUS.
807
if we may be allowed to accord an entire degree of confidence to the
facts derived from the practice of this surgeon.
  A.  The  ordinary process.—The  patient  being arranged,  and
placed, and held in  the  same manner as for fistula, except that his
two thighs, and not  one  only, are to be  separated by a pillow, and
bent at a right angle upon the trunk, while an assistant  keeps  open
the  buttocks and stretches the skin, the surgeon  encircles the dis-
eased part below by means of two semilunar incisions, which  unite
at. the coccyx and perineum, so as to form an ellipse ; dissects this
ellipse on its outer side  from below upwards, and to the right, and
then to the  left; detaches it by degrees from the surrounding tissues,
while taking care to leave nothing altered external to it; stops when
he arrives at the  sphincter ; introduces  the  left forefinger  into the
anus ; makes use of it as a hook to depress the scirrhous ring, which
latter he endeavors to bring to the outside at the same time that an as-
sistant makes traction upon the dissected ellipse ; retakes  the bistoury
in his right  hand, and continues to cut in a circular direction the ad-
hesions which exist between this portion and the circumjacent layers,
as far as to above the limits of the disease, if it is possible, and ter-
minates the operation by detaching the whole by free strokes  with
the scissors curved,  flatwise, or even by means of the bistoury which
he has made use of up to this time.
  I. When the cancer is deeper, and  more  adherent, or comprises
a greater thickness of  the tissues, M.  Lisfranc  divides vertically
the  angle or posterior wall  of  the dissected  ellipse, by commencing
with a strong pair of scissors and prolonging his  incision to a  point
sufficiently  high in  the  rectum.  The assistants  afterwards  make
traction upon the remainder of the circle by means  of erignes or
strong forceps, while the operator prolongs  the dissection above as
far  as possible, by means of the bistoury guided upon the finger,
introduced in the anus, and  by the thumb applied upon the outer side
of the flap.  When  he has gone beyond the limits of the disease the
curved scissors may be substituted for the bistoury as before, in  order
to separate, circularly, the dissected mass from the portion of the
rectum which is to remain.  We introduce its extremity into the poste-
rior  incision, in order to  embrace in succession its  two halves, and to
divide them from behind  forwards, while taking  care to act on the
sound tissues, and to increase our precautions  as we approach the
genito-urinary  organs.
  II. In women an intelligent assistant, with one or two fingers  intro-
duced into the vagina, watches the movements of the bistoury or scis-
sors  in this direction, while the surgeon dissects the cancer in front, or
endeavors to excise  it at its depth.  In man the urethra, prostate and
bladder  render this  stage of the operation  still more delicate.  A
strong catheter, kept up the natural passage, is doubtless a valuable
guide, but one which would be  but of feeble assistance if the surgeon
had  not constantly present before his mind his knowledge of the sur-
gical anatomy  which relates to the perineum, or if  he were unprac-
tised in the  employment  of cutting instruments.
  III.  When the excision is finished, the operator reapplies his finger
upon every point of  the wound.   If he perceives any tubercles, flaps,
or remnants of altered  tissues which  have escaped him, he imme- 
808
NEW ELEMENTS OF OPERATIVE SURGERY.
  diately seizes them with an erigne or a forceps, and instantly excises
  them with the bistoury or scissors, whether they be in the interior or
  on the skin.  The arteries divided belong to the same branches as in
  the operation of fistula in ano.   To these must  be added, in  some
  cases, the transverse artery and  the superficial arteries of the peri-
  neum.   The ligature  is to be applied upon all those which can be
  seen, in proportion as we divide them.  Otherwise we should run so
  much the greater risk of not finding them afterwards, because from
  being stretched and elongated at the moment of making the section,
  they ascend very high up into the  pelvis, and, if we  wish to bring
  them to the outside by making traction upon the extremity of the in-
  testine, the compression we exercise upon them  prevents the blood
  escaping from  their mouths.   Nevertheless they  are rarely of suffi-
  cient size to give rise to the apprehension of any serious hemorrhage.
  Should  this hemorrhage have taken place we combat it by refrige-
 rants, styptics,  small balls of lint methodically applied, tamponing, or
 in a word, by one of the methods  pointed out in  the preceding arti-
 cles.   If during the course of the operation the blood should flow to
 such  extent as to interfere with the surgeon, we might, as, according
 to M. Pinault, M. Lisfranc directs, wait a  few moments and check it
 with  lint saturated  with cold  water, should it not be practicable to
 have  recourse to the ligature  or torsion.
  IV. The meche is still more important after this operation than in
 any of the others.  It should  be of large size and  long.   It is requi-
 site that the finger should precede it and incline it strongly backwards
 m order to find the new opening  of the rectum, and that it  should
 afterwards make it vibrate in  the contrary direction in order that it
 may  penetrate   with  facility.  A portion of  linen besmeared  or
 covered  with cerate  and applied over the bleeding surface, then
 receives the extremity of the meche, over which we place coarse lint.
 several  plumasseaux and compresses, and the double T bandage
  V.  When we omit the meche in the beginning, and limit ourselves
 to spreading upon the wound the perforated linen which is to receive
 the lint, so as not to have recourse to tents until at  the tenth or fif-
 teenth day, the first  dressing becomes more  prompt and  is per-
 haps  a  little more easy; but we  create for ourselves difficulties  in
 perspective, so that it would be more  rational to proceed in the man-
 ner 1  have just pointed out.
  VI. The wound,  which is inundated for some davs with a copious
 suppuration of a grey and blackish color, mingled with faecal matters
 becomes ^ised  by degrees  and begins  to contract  from  the  5
 teenth to the twentieth day.  At the same time that the skin is being
 as it were, dragged in towards the pelvis,  the intestinal orifice real-'
glutmated  to the parts which  surround  it, approximates to the exte-
rior ;  so that finally nothing more remains than  an annular loss of sub
stance to the he.ght of an inch or even less; and that the preseiwed
fibres  of the levator am, of the aponeuroses and termination of tt»
rectum,  and of  the  other lamella^ by being blendedZglTr in  one
SIX;*UC\t0 a °ertam  eXle1^' the sPhinc*er  muscle, supposing
* should have been necessary to have removed this, leaving frtrd!

X^X*"*        y        rmity than <;°uld hav* been 
CANCERS OF THE  ANUS.
809
   VII.  In order that this cure  may be  certain and permanent, it. is
important not to abandon suddenly the  use of dilating bodies.  The
new anus has so great a tendency to  contract, (coarcter,) that if the
meches were not continued at  least for  some weeks after the  cicatri-
zation of the wound, and renewed from  time  to  time, during the
space of several months, the greater number of patients would not
fail to become soon affected with so great a degree of contraction as
to counterbalance the price of the  sufferings they have endured and
the benefits of the operation, though it may have been performed in
the most judicious manner.
   B.  New process.—If the cancer constitutes a ring which  is only
an inch in height, I commence by laying it open behind.  Afterwards,
securing it with the finger or a good pair of erignes, I bring it down
completely to the outside. A curved needle  then enables me  to pass
through its root a series of threads from above downwards, or from
the rectum towards the skin.   The cancer being now detached from
the sound parts by means of a circular  incision, either from the skin
towards the mucous tissue, or  from the latter towards the former,
by means of the bistoury or  scissors,  is  immediately removed at
three or four lines  on  this side of each point traversed  by the
threads.  By seizing these latter, in order to knot them outside, we
approximate and place in contact the two circles of the  wound, in
such manner as to accomplish  their union by first intention.  When
the disease goes higher up, I first dissect it  from below upwards as in
the ordinary process, and even to a certain  distance beyond.  It is
at this moment that I insert the threads  from  space to space upon the
sound portion of the detached  rectum, and above the altered tissue,
as if  for the purpose of securing it, and afterwards  from  above
downwards through the  cutaneous lip of the wound.   A  few cuts
with the scissors or bistoury immediately cause the cancer to become
separated, and the approximation of the two halves of each  thread
afterwards brings down without any difficulty the  intestinal circle,
preserved, as far as to a line with the tegumentary circle.  Should it
become necessary to remove  unequal plates instead of a  complete
ring from the anus, we might circumscribe each of them in  an
ellipse, the two lateral angles,  and the lower angle  of which  should
be immediately reunited, and  each closed  by two points  of  suture.
These three modifications of the process have been used by me in
practice.  From their enabling us to  fill up the wound with mucous
or cutaneous  tissue, and by first intention, they  render the  occur-
rence of hemorrhage more difficult, the cure more  prompt, and the
reaction less serious, without at the same time leaving any inodular
cicatrices.
                      § II.—Appreciation.

  Cancer of the anus, therefore, may be submitted to the chances of
extirpation, like that of the breast, when without causing too  great a
destruction of parts, it would appear to  be  practicable  to  remove it
entire, that is to say, when we  may reach completely beyond it with
the finger, and when it is limited to the walls of the intestine, or at
least retains a certain degree of mobility, and has not  yet extended
beyond  its line of demarcation with the constituent parts of the is-
  vol. in.                     102 
810
NEW ELEMENTS OF OPERATIVE SURGERY.
chio-rectal excavations.  In other cases, and in all  those in which
its adhesions with the vagina, bladder, prostate, or urethra, shall be
found to be too intimate to be destroyed with facility, it will be ad-
visable to renounce it in the same way as we should  do also in any
other region.  The patient operated  upon  by M.  Ricord,  (Journ.
Hebd., t. XL, p. 534,) died in consequence of it; while those of M.
V. Mott were perfectly restored.   It was a cancerous tumor of the
rectum, and not the anus itself which was successfully extirpated by
M.  Torri, (Sul. le Extirpazz. di un  Cancero, &c, Bologna, 1837.)
We cannot very clearlv understand what the disease was in the pa-
tient whom M. Stirling. (Transact. Med., 1833, t. II., p. 349,) states
that he  cured.  M. Mandt, (Rev.  Aled., 1836, t. III., p. 264—Klei-
nerVs Repert., Jan., 1836.) in one case had a recto-vaginal fistula.  M.
Baumes, (Bull, de VAcad. Roy. de Med., t. I., p. 936,) asserts that he
has completely succeeded  with  this operation.  The same  remark
applies to M. Maurin, (Rev. Med., 1831, t. I., p. 194.) In the patient of
M.  Haime, the incontinence of the  fiscal  matters persisted.  Of the
six  patients operated upon by me, one died of phlebitis at the expira-
tion of ten days, a  second from exhaustion on  the  seventh day, a
third with a pound of blood effused into the upper part of the rec-
tum, while the fourth and fifth were radically cured.  The sixth can-
not  retain his fasces, and is at the present day, (1839,) which  is three
years since the operation, in a state approaching to marasmus.
           [CONCLUDING  REMARKS,

                        BY  V.  MOTT.

  In regard to  spina bifida, to which allusion has  been made in a
note in the last volume, [see Supplemental Appendix, Vol. II., p. 99,]
a remarkable case has recently  presented itself in my practice.  Its
locality was very unusual, that  is, in the lower part of the cervical
vertebras, and upper dorsal, in a female child aged nine days.   The
tumor was congenital and globular, about one  and  a  half inches in
diameter, and attached by a narrow pedicle, about half an inch dia-
meter,  between the spinous processes.   It was said  to have dimin-
ished slightly since the child's  birth, and evidently  contained a lim-
pid fluid.  There was no deficiency  or defect of  development in the
median line between  the  spinous processes, where  it was situated
I ressure on the tumor produced no effect on  the child, which was
otherwise perfectly healthy and well formed.  No fluctuation  could
be produced by pressing the fontanelles  and tumor  alternately   It
was, however, believed to have a communication with the cavity of
the spine, and with the consent  of the parents, its extirpation was de-
termined upon.   This I accordingly did on the following day  when
a communication, about the size of a crow-quill,  was found leading
into the  cavity of the spinal marrow.  The tumor contained  the
fluid of an ordinary spina bifida.   An elliptical incision  was  made 
CONCLUDING REMARKS.
811
on each side of the tumor into the sound portion of the integuments,
and the mass extirpated at its root.   The lips of the wound were
closed, as in hare-lip, by two interrupted sutures, aided by adhesive
plaster.  The plaster was renewed twice in the course of ten days,
at the  expiration of which period the wound was found perfectly
healed.
   Immobility of the Lower Jaw.—This malady, as far as I know, has
never formed a distinct chapter in any systematic work on surgery.
I therefore, perhaps, may claim some originality for introducing it to
the notice of the  profession.  The more so, from my having for the
last  thirty years and upwards, met with many cases of this kind and
treated them successfully.  The means which I have resorted to, may
possibly have been used by  others before my time, but I  am not
aware of the fact.  We are sure that many of the cases we  have
met with, had been abandoned by others as altogether hopeless and
irremediable.
   All surgeons no doubt would, or ought to  think of expedients to
relieve difficulties and  embarrassments  connected with the full and
normal functions  of organs.  But as this subject has not claimed that
share of attention which its importance demands, we think  no  apol-
ogy on our part need be offered  for here introducing it in a distinct
article.  And we know of no epithet more appropriate  to  the affec-
tion, than that which  is implied by the  name  we have given to it.
It is, in our opinion, an important surgical subject, and  especially so,
as it is one which frequently is very difficult to treat.  The difficulty
in this affection depends, according to my observation, upon three dif-
ferent causes.
   First.—The first and most frequent cause is the formation of firm
unyielding cicatrices, resembling as it  were adventitious  ligaments,
connecting the upper and the lower jaw bones, in such a way as ut-
terly to prevent any downward movement of the lower jaw ; which
fastenings, if they have continued for a number of years, as we have
seen in several instances, create  a positive deformity in the configu-
ration and symmetrical proportions of the features of the  face.  As,
for example, in the remarkable disproportion  in  the development of
the chin and the entire  lower jaw bone, as compared  with the rest
of the face.  And from the long continued fixedness  of  the lower
jaw  bone, we find that besides this outward deformity, the front teeth
also  frequently present, especially in  the cases of long standing, an
irregularity, and also a disproportion, which is utterly un-human in ap-
pearance.  When not  opposed to each other,  they grow to  an  inor-
dinate length, and exhibit a carniverous or canine aspect, as though
they were intended exclusively for tearing purposes, instead of ful-
filling the functions of  incisors.
   Second.—The second cause appears  to lie  in the muscles them-
selves,  in the form  of a preternatural  rigidity or  dynamic con-
traction, as is evident to the sight as well as to the  touch.   Most
of the cases I have seen and treated of this  description,  have been
young persons, in  whom the disease was the result of the violent
action of mercury upon the mouth and adjacent parts, exhibited for
some form  of fever, for scarlatina, &c.   I have traced these cases
to that cause, though it is difficult to understand how such  an effect 
812
NEW ELEMENTS OF OPERATIVE SURGERY.
 should be produced by it;  unless it is from the unwillingness in  the
 individual to exercise the muscles of the lower jaw, while in the  en-
 gorged condition which exists in the tissues during mercurial action ;
 the muscles from this quiescent state seeming by degrees to take on
 an unnatural  spastic  rigidity.  In all the  cases  but  one which we
 have encountered, there was more or less of a normal action in  the
 pterygoid  muscles, by  which a  trifling lateral  movement of  the
 lower jaw was perceptible.  In  the case in which  none of these
 movements could in any way be detected, all my efforts, which were
 varied and very powerful, were  utterly  unavailing in opening  the
 mouth; as will be seen in the details farther on.
   Third.—It may be  proper to enumerate a third cause.  This,  ac-
 cording to recent pathological observations, as is seen in a note in the
 text, has been found to consist in  an osseous union, by means of a
 bony plate which  extended  from  the coronoid process to the supe-
 rior* maxillary bone, by  which the  lower jaw became perfectly im-
 movable.   These, we hope, are rare instances, but it is possible that
 the irremediable case  we have above alluded to, may have been ren-
 dered incurable by such an  adventitious formation.   If such a con-
 dition of things could  be known at the time, probably some  sort of
 an operation might be devised to  sever or exsect this bony commu-
 nication, and thereby  at once  open the jaws.  In all my cases but
 one, even though there  was not any appreciable movement of the
 jaw downwards, I have been enabled to  ascertain by a careful ex-
 amination, that there still existed some trifling lateral motion.   As
 far as my experience has gone, I would therefore consider this as the
 best diagnostic or test for justifying the process of opening the jaws
 which I have adopted so frequently with success.   Indeed, I should
 be unwilling to offer a favorable opinion  of the result of the opera-
 tion, without this previous evidence of the natural condition of the
 articulating surfaces.  My process of surgical  treatment for the  re-
 lief of this distressing difficulty, will be better understood by the details
 of the following cases ; by which  it will be found, that almost every
 case has had  some peculiarity which has  made it necessary to vary
 the steps of the operation.   The instrument upon  which I have  re-
 lied, after preparing the  patient by the necessary previous incisions,
 is  constructed upon the screw and lever  principle.  It is one which
 I got up to meet the exigencies of the third case, without ever having
 seen or heard of any thing  of the kind.   Though I confess I have
 since met in the Armamentarium Chirurgicum of Scultetus, the figure
 of one of a similar construction.
   Case I.—The first case occurred about the year 1812, in a little
 girl.  There was extensive exfoliation of  all the alveolar margin  on
 the upper jaw on both sides.  The lower  jaw was quite firmly fixed.
 After removing the necrosis, and  waiting until the gum healed, the
 cicatrices were then  freely divided from  within the mouth.   Then
 by forcibly seizing hold of  the  chin  and side of the jaw with both
 my hands,  and putting  my thumbs on the teeth  of the lower jaw
 through the opening made by the removal of the necrosis, while the
 head  was very firmly held, I succeeded in depressing  the lower
jaw so as to open it sufficiently wide.  The little girl was about nine
years old, and of good healthy constitution, and the disease was 
CONCLUDING REMARKS.
818
 produced by the action of mercury given for a remittent fever.  She
 entirely recovered the use of her jaw by the process mentioned.
   Case II.—The second case was an officer of the U. S. army, from
 Green Bay.   His lower jaw was almost immovable from a cicatrix
 extending from the last molar tooth, to  some  distance forward.  It
 had been of several months' duration, and was, I think, also  the re-
 sult of mercurial action.  The cicatrix was divided with a  scalpel,
 and the jaw  forcibly depressed  at  the  chin, by which means the
 mouth was opened, and the cure was perfect.
   Case III.—During the winter of 1828,  a  young man  about 21
 years of age, from  North Carolina, called upon me with the lower
 jaw almost immovably fixed to the upper.  There  was not the least
 motion to be discovered in a  downward direction, nor was the most
 powerful  effort with the hand upon the chin, able in the slightest de-
 gree to alter its situation.
   He had been in this deplorable state for  between  ten and eleven
 years.  Unable during that time to chew a mouthful of food, he in-
 troduced  all the solid aliment which passed into his stomach through
 an opening on the right side, occasioned by a small  aperture from an
 irregularity of the bicuspides teeth.
   On the left side, just within the angle of the mouth, and opposite
 the situation of the cuspidatus tooth, a very  firm band was to  be seen
 and felt, reaching from this point  along the alveolar ridge to the co-
 ronoid process.   It was of more than ligamentous hardness.
   Along the whole  course of this adhesion of the cheek to the gum
 of the lower  jaw,  there was not the vestige of  a tooth; and he
 stated that from this part a large piece of the jaw had been formerly
 separated with the teeth attached to it.   This morbid adhesion had
 been several times freely divided, but no  depression of the lower
 jaw could be effected.  It was cut from within the mouth in different
 directions, but never allowed the least motion to the jaw.
   From his being able to give  a little  lateral motion to the lower
jaw, I felt  encouraged to hope, that some relief might  be afforded
 him, and that his mouth, by  some  powerful efforts, might  yet be
 opened.   He  consented with  great cheerfulness to any operation
 which I thought could be performed, to enable him  to receive food
 with more satisfaction, and restore the power of  speaking, which
 was also  very much impaired.   If this  could be  accomplished, it
 would, moreover, very  much improve his  expression generally, as
 his face had become very much contracted  and misshapen.
   Seated in a chair, I made an incision from the angle of the mouth
 on the left side, through the cheek, and carried it to  near the edge of
 the coronoid  process, dividing the firm cicatrix  within  completely.
 Then cut the adhesion freely from the upper and lower jaws, so as to
 relieve the jaws entirely from all restraint from that cause.   A piece
of very broad tape  was how conveyed between the teeth by means
of a probe and spatula, and tied some distance below the chin.  The
head was  now firmly held, and with all the force I  could exert in
the loop of this tape, not the least yielding of the lower jaw could be
discovered.
   As no force which I could  exert  would enable  me to  open the
mouth, I was prepared to apply the mechanical principle of the screw 
814
NEW ELEMENTS  OF  OPERATIVE SURGERY.
 and lever.   For this purpose we had prepared the instrument already
 alluded to, and which is composed of two steel plates, about three inch-
 es in length.  When applied to each other they were of a wedge shape.
 To the large end was  attached a screw, with a broad handle, which,
 when  turned, caused the thin extremity of the plates to expand.  (See
 figure.)  This powerful combination  of the lever and screw enabled
 us to open the mouth completely.
   With considerable difficulty we  succeeded  in insinuating this vice
 between the range of teeth on the  left side, being careful to have
 it rest  along their whole course as much  as  possible.  It was then
 expanded by turning  the screw,  and such was the report that at-
 tended the yielding  of the lower jaw, that several exclaimed that the
 jaw was broken; but  to me the noise was like the  laceration of lig-
 aments, and not such as attends the fracture of a bone.  The mouth
 was immediately opened to a sufficient extent.
   The wound of the cheek was closed with three interrupted sutures,
 aided with strips of  adhesive plaster.  From  the mouth being kept
 constantly open for several days, by the instrument  secured between
 the teeth, it occasioned much strain upon the  stitches,  and made the
 adhesive strips of material importance.
  Either the instrument or a soft piece of wood  was placed con-
 stantly between the jaws to keep the mouth sufficiently open until
 the cheek had healed.  During this time he received his  drinks  and
 liquid nourishment from a spoon or the spout of a tea-pot.  When in
 this way they were  conveyed well towards the base of the tongue,
 he was enabled to swallow without much  inconvenience.
  As soon  as  the external wound in the cheek was healed, the in-
 strument was removed, except at night, and occasionally during the
 day, and he was now permitted to  move the lower jaw.  To prevent
the cheek from adhering to the jaws internally, pieces of  sponge
were constantly interposed.  To enable the jaws to approximate, it
was  necessary to remove the last molar tooth of the upper and lower
 jaw  of the left side.  Several of the  incisors were of the most ex-
 traordinary length, and required to be filed off, before a proper use
 could be made of the others.
  He gradually  acquired the power of closing the jaws, and was
greatly delighted with  the result of an operation which enabled him
to chew his food, and  enjoy his meals as other persons, which had
 
CONCLUDING REMARKS.
815
given proportion to his features, and the ability to converse and arti-
culate distinctly.  [See this case in Am. Journ. Aled. Sc, 1829. vol.
V., p.  106.]
   Explanation  of the Figure.—aa, the two levers bent at right an-
gles, and united  to the fulcra cc, by a joint,  d, the screw  passing
through the centre of the bar, and acting upon the angles bb, which
are notched to receive its point.
   Case IV.—A merchant from  Louisiana, and also the result of
mercury.  There was not, nor had there been, any necrosis in either
jaw.   When dividing the bands of adhesion with the narrow  straight
bistoury,  the screw instrument, found so  efficient in the last case,
was passed between the incisores, and the mouth readily opened.
The cure was perfect.
   Case V.—The fifth case was that of the young lady from  Massa-
chusetts, where I found it necessary also to procure a large patch for
the whole side of the cheek, from the neck, by a geno-cheiloplastic
process; previously exsecting  all the cicatrix,  and unlocking  the
jaw by the screw lever.   See this case in  a  note under  Anaplasty,
in Vol. I., p. 706 of this  work.
   Case VI.—This (1831) was an interesting young lady from Louis-
inana, about eighteen years old, who  for six years had had the jaws
closed.  The cause was the action  of mercury.   The adhesions
were firm on each side.  They could easily be got at from within the
mouth and divided, but the jaw could  be  opened only a  little way,
although a screw instrument was used on each side instead of in
front, as in the previous cases.   In order to get access, several of
the teeth were filed or sawed off.  All  efforts, however, were inef-
fectual.  Three  different  attempts were made at intervals of several
weeks, and each were persevered in for some time.   In no instance
have I used half the force employed  in the present case.  The last
attempt I made almost  brought  on convulsions from the pain pro-
duced, and I only wonder that the lower jaw did not break. I re-
gret that the  knowledge  of myotomy we now possess, was not at
that time understood ; for I am persuaded, that if I had then known
as much of the benefit of dividing or  excising muscles and tendons,
which we now have, I might have restored  this interesting young
lady.   The subcutaneous division by  a straight bistoury of the mas-
seter muscles, would in all probability, with a moderate  amount of
force, have opened the mouth.—I had previously, on several occa-
sions, divided in part this muscle, where I  was obliged to lay open
the cheek.  All  this disagreeable deformity might in her  case have
been avoided by the complete subcutaneous division of these mus-
cles.  I was grieved to abandon this case, the only one in which"  I
had then, or have hitherto, failed in effecting a perfect cure.
  Case VII.—This was a young man, who when a boy eight or ten
years before, had a necrosis and ulcerations from fhe operation of
mercury.  Various attempts had been made some years antecedently
to open the mouth, but they  all  failed.  I removed  the adhesions
freely  with the  probe-pointed  bistoury, and  with the screw-lever
readily opened the mouth to its full extent.
  Case VIII.—An  eighth case,  (also 1831,) was a child from  the
District (now State) of  Maine,  who had had  six months  before, 
816
NEW ELEMENTS  OF OPERATIVE SURGERY.
 scarlatina anginosa.  Considerable ulceration  took place  about the
 cheek and gum, followed by necrosis of the upper  jaw.   When the
 ulcerations healed the jaw became closed.   The necrosed  portion of
 the  bone was  loose, containing several  of the teeth, all of which
 were  taken away.   The screw  was  then applied, and the mouth
 opened.
   Case IX.—A little girl from South Carolina.  It was the effect of
 salivation and  necrosis.   The adhesions were divided  within the
 mouth, the instrument applied, and the jaws readily opened.
   Case X.—(Dec, 1841.)  A little girl from Dutchess County, aged
 ten years.  From the free use of calomel  for  a supposed  inflamma-
 tion of the intestines, a profuse ptyalism was the consequence.   The
 ulcerations which took place on the inside  of the cheeks  were  fol-
 lowed, on healing, with a perfect closure of the jaws, since  the month
 of Feb.,  1840.   There  was no necrosis of  either jaw bone.  After
 dividing  the adhesions  on eacn siae  freely, with a straight probe-
 pointed bistoury, within the mouth, I was enabled by means of my
 fingers to depress the lower jaw sufficiently to admit one finger.  The
 instrument was now placed between the incisor teeth, and  the mouth
 opened to the full extent.   This case resulted  in a perfect  cure.
  Cases  XL, XII., XIII., XIV., XV., XVI.—These cases were all
 of a similar nature to the generality of the  cases  above described,
 and  all resulted in  a perfect cure by the means  above employed.
 One of these,  (1843,) I will  remark was a fine boy, aged twelve
 years,  son  of Bishop W---- of Maryland, whose jaws  had been
 firmly closed for eight years.  The cause was a fall upon his chin on
 the bannister of a staircase.   In the fall, he was received  under the
 chin, from which the inability to open the  mouth ensued.  About a
 year before I saw him, a ladder in falling, struck the anterior  and
 upper part of the chin, which  suddenly opened his mouth ;  but after
 a short time the  rigidity returned,  and  the jaws were  again closed.
 There were no morbid or adventitious adhesions or bands to  be found.
 The masseter muscles on each side were remarkably small  and hard.
 The most trifling lateral motion only was perceptible.   The lower
 jaw was  so closely shut that it was difficult to introduce a half dollar
between the teeth.  In this case  there was the  least lateral motion I
ever saw, except in the young lady above, in whom  alone I did  not
succeed by my process.   This case had  been given up as hopeless
by all the surgeons whom he had  consulted  in different parts of the
country ; none of whom had recommended  any mechanical power
to overcome the difficulty.  The case required a great depressing
effort upon the chin,  and a  small lever between the  teeth,  to enable
 me to introduce the  blades of the  screw-lever between them   As
soon as it was barely between them, the action of the screw readilv
made room enough to place the instrument fairly between the inci
sores.  The mouth was then sufficienly opened.  I gave him an in
strument, with a request that it should be used  at night between  the
molares teeth, while  asleep, in order to keep the mouth open   After
a week or two I had made for him a small instrument  on  the same
principle, which  he used from  time to time for many months in order
to continue the  success  of the treatment.  In all  the cases upon
 which 1 have operated, my plan has been, for some time after open 
CONCLUDING  REMARKS.                  817
ing the mouth, to use the instrument  from time to time, either be-
tween the molares, or between the incisores  in front; and partic-
ularly, where the instrument was not thus employed, to introduce a
piece of soft wood or fine piece of cork on  either side, between the
molares, at night, securing it by a string around the neck.  During
the day I have insisted upon the practice of chewing hard crackers
or hard bread, or sea-biscuit, in order to  initiate  the muscles into
their normal functions.
  It may be interesting to those who have not  seen these cases, for
me to state, that it is my opinion, th-at where  there is no lateral mo-
tion whatever perceptible,  from the action of the pterygoid muscles,
then it may reasonably be inferred that anchylosis  has taken  place,
and that but  little hope can be  entertained for the success of this
treatment.  Where there  is the least lateral motion, there will then
be the greatest difficulty.   I may say that my last case occurred be-
tween two and three  months since, (Nov., 1846,) in a little girl who
was successfully treated by the mode above  described.  V. Mott.]
  New York, Feb., 1847.
                  Artery, Tying Internal Iliac.

   [As the last of this work was passing through press, I received a letter
from Dr. Mott, giving the details of a recent operation successfully per-
formed by him, an extract from which is subjoined.  G. *B.]

                                                 "March 8, 1856.
   " Yesterday a patient of mine left the city, on whom I tied the inter-
nal iliac artery, five weeks since.  The wound was nearly healed.  It
was  a youug woman aged twenty years, who from, a punctured wound
from a penknife, through the thick part of the glutei muscles of the left
side of the nates.   The tumor was of two years' growth, and about the
size of a punch-bowl inverted that would contain two quarts.  The liga-
ture came away on the twenty-first day.  This  is the second time in
which I have tied this artery.   Both have tenninated successfully."
   vol. m.                    103 
 
AMERICAN  APPENDIX.

    BY G. C.  BLACKMAN, M. D.
                           ANKYLOSIS.

   Under this head we  propose  to notice what has  been done since the
last edition of this work, in the  treatment of ankylosis of the temporo
maxillary articulation,  and of the hip and knee.   True ankylosis at the
former is seldom observed.  There is one specimen in  the Museum of
the Royal College of Surgeons  of England, in  which the fusion of the
bones is complete.   The affection had  existed for fifty years  before the
patient's death.  Mr. Pittard has given an  account of this case in the
 Cycl. Anat. Sf Phys.,  vol. iv.  p.  939.  Dr. Wernher  has reported in
Oppenheim's Zeitschrift, Bd. xliv., a case which was successfully treated
by incisions and dilatations.  The buccal mucous membrane was at-
tached to the gums at the anterior edges of the bony arches which con-
nected the upper and lower jaws.  The gums were separated by an in-
cision from the cheeks and lips, and a broad portion of  the connecting
arch on either side removed with a small saw.
   According to Dr. Wernher, ankylosis of the  lower jaw may occur in
three localities.  1. The head of the condyle may  become fixed in its
glenoid cavity.   This is the most frequent form, examples of  which are
recorded by Sandifort,  Blandin, Cruveilheir, Howship, Holscher, Hyrtl,
&c.  2. The coronoid process may become  attached to the  zygomatic
arch.   Of this two cases have been reported by Sandifort and  Sebastian.
3. The  alveolar processes may  become united.  Of this there are three
examples on record, besides the one to which we have  above referred.
Of fifteen cases of ankylosis of the lower jaw  collected by Dr.  Wernher,
both sides were affected in seven, and one side in  eight.  In the three
examples of osseous connection of  the alveoli, the  incisors were some-
what separated.   An abstract of Dr.  Wernher's paper may be found in
the American Journal of Aledical Sciences, April,  1852, p. 526.
   In a case of true ankylosis of  the lower jaw, in addition to the division
of the masseter muscle  on the affected side, Dr. Carnochan endeavored,
by making a section of the bone according to Dr. Barton's principle, to
form an artificial joint.  This however  proved  insufficient, and Dr. C.
suggests that in similar cases, the entire exsection of the bone should be
made.
   In cases of false ankylosis of the lower jaw the instrument devised and
used by Dr. J. Rhea Barton has been successfully employed by Dr. Mutter 
 820            NEW ELEMENTS OF OPERATIVE SURGERY.

and myself.  It consists of two plates of a horse-shoe shape, which are
separated by a screw.   The plates are broad and may  be covered with
caoutchouc, so as to rest securely upon the teeth  without subjecting
them  to injury.  We have reported  a case in  the  Amer.  Jour. Med.
Sciences for October, 1845, which was  treated by this  instrument, and
in which an extensive  plastic operation was  performed to remedy the
deformity resulting from a loss of the  cheek and a part of the upper lip.
The masseter muscle has been  not unfrequently divided with the object
of assisting the removal of the  ankylosis.   In the former edition of this
work, full space was  given to the different claimants of priority in  this
operation, but it  seems  they were all anticipated by M.  Dieulafoy, of
Toulouse, who divided this muscle in  1838.   AVith the masseter he like-
wise divided the anterior fibres of  the pterygoid muscles.   A notice of
this case may be found in the Amer. Joitr. Med. Sciences, vol. xxvi.,
1839, p. 218.   Dr. Townsend also referred to it in the Appendix to the
last edition.
  In  the London Lancet for November, 1851, Am. Ed.,  p.  362, Dr.
Little of London, has reported an interesting  case,  in which he divided
both  masseter  muscles.   At the  close of his  report he offers the  fol-
lowing judicious remarks:
  " It may not be superfluous to add,  as a  caution to over-ready opera-
tors, that discrimination of suitable cases is not invariably easy.  Above
all, it should be remembered that many cases of closure of  the maxillae
occur in nervous females, in which of  course, an operation is not advis-
able, as the onset, departure, and recurrence of such contractions may
occur suddenly or without premonitory phenomena.   They are, in short,
sometimes intermittent in  their character.   In no case of muscular con-
traction should operation  be employed  until after persevering trial of
suitable mechanical means by the practitioner himself."
  The annexed figure will, at a glance, recall to the mind of the surgeon
the important organs  in the vicinity of this muscle, which, of course, he
will endeavor to avoid. 
AMERICAN APPENDIX.
821
               Ankylosis  of Coxo-Femoral Articulation.

   In addition to  the cases in which Drs. J. Rhea  Barton and J. Kear-
ny Rodgers operated, an attempt was made in 1847, by M. Maisonneuve,
of Paris, to establish an artificial joint by making a section of the bone.
The flexion on the pelvis was overcome, but  a false joint was  not ob-
tained.  The editors of the Compendium  de  Chirurgie Pratique, tome
deuxieme, p. 475,  state that they saw this patient when he was pre-
sented to the  Societe de Chirurgie, eighteen months after  the operation,
and  that the patient could then walk, though the movements must have
had  their seat in the vertebral column and the hip-joint of the other side.
M. Vidal refers in his  Traite de Pathologie Externe, &c,  vol. 2, p. 637,
to an instance in  which M.  Velpeau has performed this  operation, but
we have been unable to find the details of the case.

                       Ankylosis of Knee-Joint.

   Dr.  Barton's operation  for  remedying the deformity arising from an-
kylosis (angular) at the#  knee joint has been frequently repeated  and
with the most gratifying results.  Among  our own countrymen it has
been done  by Drs. Gibson,  Mutter,  Pancoast, Post, and Burr.   Dr.
Buck in three cases has deviated from the plan adopted by Dr. Barton,
and  the surgeons  above mentioned, by excising the  knee-joint itself.   M.
Sedillot, in his Traite de Med.  Oper.  2d Ed. vol. 1., p. 536, asserts
that M. Mayer,  of Wurzburgh, has performed fifteen  operations, on
eight patients, and that in one instance only was the proceeding followed
by a fatal result.
   Of the twelve cases collected  by Dr. Sargeant, of Philadelphia, in his
annotations to Mr. Miller's Principles of Surgery, 3d Am. Ed., in one
only was the result fatal.
   This operation  has been denounced by many European  surgeons, and
there can be no doubt that it should not be resorted to without due con-
sideration.  The  cases in which Dr. Barton has recommended it are as
follows:
   " I believe the  operation would be justifiable only under the following
circumstances, viz.: where the patient's general health is good,  and his
constitution sufficiently strong; where the rigidity  is not confined to the
soft parts,  but is actually occasioned by a consolidation  of  the joint;
where  all the muscles and tendons that were  essential to the ordinary
movements of the former  joint are sound, and not incorporated  by firm
adhesion with the  adjacent structure;  where  the  disease causing the
deformity has entirely  subsided ;  where the operation can be, performed
through the original point of motion, or so near to it that the use of most
of the tendons and muscles will not be lost; and finally,  where the de-
formity or inconvenience is such as will induce the  patient to endure the
pain, and even the risk of the operation."
   Prof. Brainard, of Chicago, proposes as a substitute for  this operation,
perforation of the bone as  shown in the following figure.
   In this manner the strength of the bone is so diminished  that it may be
bent, without breaking, or if desired, it may be readily fractured.  This 
822
NEW ELEMENTS OF OPERATIVE  SURGERY.
method would certainly be attended with less risk to the patient, than
that devised by Dr. Barton.
                         ANAESTHESIA.

  Although the attention of the ancients  was directed towards the at-
tainment of the means of producing insensibility to pain during the per-
formance of  surgical operations, it was not until the middle of the nine-
teenth century that this desirable object was satisfactorily accomplished.
17W «rTnment-° ^ **00Fe\at St- forge's Hospital, London, in
1/84 of compressing the principal nerves of a limb, previous to an i
rotation  was but partially successful, and was soon Abandoned   Eve"
the hint thrown out by Sir Humphrev Daw in >.,*o  r>/,„  •   /   j ™ f
soplacad  Researches^Lond.  lVPa&"&^^£
might destroy  physical pain so as to be advantageously used in suLical
operations, was not acted  upon in such a manner as to d^^1.9
until Dr. Horace Wells, a dentist of Hartford  Po™ J?   7   notL?>
subject in 1844, and commenced a series ofliSiZ^Ji *°0k °,f ^
which have been truly astonishing, both as reSrfsT £iS?  ^f* °i
on the human race, ajd  the disastrous aYffi tJ^oSTW
Wells himself, who died by his own  hands in 1848   tuJ. k  *       •
meats made in Hartford, /ere  during the  exVaetL of Ite^'anlS 
ANERICAN  APPENDIX.                    823
the nitrous oxyde gas.  These were successful in more than twenty cases
and very naturally excited much attention.   Dr. Marcy of Hartford sug-
gested  sulphuric  ether  as a preferable agent for  this  purpose,  and
actually employed it in  removing an encysted tumor from  the  scalp,
and shortly afterwards, Dr. Ellsworth, of the same city, made use of it
during a surgical operation, with equal success.  During the  latter part
of the year, 1844, Dr. Wells proceeded to Boston, and gave an address
on the subject of anaesthesia, at the  Massachusetts  General Hospital.
The efforts thus made by Dr. Wells to give publicity to his experiments,
were  productive of the brilliant results which have since' been achieyed
throughout  the civilized world.  Sulphuric ether was soon selected in
preference to the nitrous oxyde gas, but in the course of a year this was
abandoned, especially  in  Europe,  for chloroform, or the terchloride of
formyle, a substance almost simultaneously discovered  by  Souberain,
Liebig and Mr. Samuel  Guthrie, of Sacket's Harbour, New-York, but
the true chemical • nature  of which was first ascertained in 1835, by
Dumas and Peligot.
  Professor Simpson of Edinburgh, was the first person rendered insen-
sible by this agent, having inhaled it,  on the evening of the 4th Novem-
ber, 1847.  In the early part of this month it was tried at the Hospital,
in that city, during the performance of three minor operations in surgery,
and in each instance the  anaesthesia  was complete.  Soon it was tried
in cases of greater magnitude, and  as soon as its marvellous powers were
known, its use became generalized throughout nearly the whole world.
But as might have been  expected of such  potent agents as sulphuric
ether and chloroform, unpleasant and  even  fatal consequences  have oc-
curred.  The  deaths attributed to  chloroform alone, already number up-
wards of fifty.   From the frequent  reports of its fatal effects, many of our
most  prominent surgeons  have abandoned its use, and returned to that
of sulphuric ether, believing this  to  be less powerful  and  hazardous,
although it is not entirely  free from  danger, as several fatal  cases have
occurred from its administration.
  The most recent writers on Surgery in Great Britain, viz. Messrs. Fer-
gusson, Skey,  and Erichsen of London, and  Mr. Miller of Edinburgh,
advocate the use of chloroform in  almost every case that can fall under
the care of the Surgeon.  Mr. Erichsen, who is the successor of Mr. Liston
at University  College Hospital, in his work on  the  Science and Art of
Surgery,  bearing  the  date of 1854, at  page 50, thus remarks: " But
though these states (affections of the  heart and brain) should render us
cautious in the employment of chloroform, they do not altogether contra-
indicate its  use ; in an old man with fatty  and dilated heart, whom I
lately cut for stone, and on whom it would have been impossible to have
operated with  any chance of success without chloroform, on account of
his  extreme irritability, no ill effects resulted from its inhalation."
  As  to the propriety of resorting to  chloroform in similar cases to  that
above mentioned it is sufficient to state that a patient with fatty  heart,
to whom Mr. Quain (Mr.  Erichsen's  colleague) administered it during
a surgical operation died.  This event too occurred almost simultaneous-
ly with the appearance of Mr. Erichsen's. work.   In some  of the fatal
cases  but a very small quantity has  been  inhaled, in others, more has
been required  to produce the fatal result.  It is maintained by  some of 
 824           NEW ELEMENTS OF OPERATIVE  SURGERY.

 the French writers that no instance of death has  occurred when  the
 patient was in the horizontal position during the inhalation, but we believe
 this opinion is without foundation.   It may be used in almost every oper-
 ation  in surgery.
   Until recently it has been supposed that chloroform could not be used
 with advantage in ophthalmic operations, especially in the extraction of
 cataract.   It was believed that the nausea and vomiting  which sometimes
 follow the administration of this agent, would lead to the evacuation of
 the vitreous humor.  We  find, however, in the London  Medical Times
 and Gazette, for Sept.  1854, that " during the last month or two " chlo-
 roform was frequently employed at the Royal London Ophthalmic Hos-
 pital  prior to the operation of extraction.   Mr. Bowman was  the first
 to resort to it, the case being one in which the  patient was so irritable,
 that the operation seemed scarcely practicable without anaesthesia.   Un-
 der the influence  of chloroform it was performed  with  great ease,  and
 no ill consequences ensued.  The reporter remarks that it has been  em-
 ployed in nearly twenty cases, and in none has there been any reason to
 regret its use.  In some, the vomiting was severe, without, however, in
 any way  damaging the  eye.  It is further  stated, that  the performance
 of the steps of the operation were much facilitated by the  perfect quie-
 tude of the eye ball which the use of chloroform  secures.   In the  dis-
 cussion of this subject at the  Royal Medical  and Chirurgical Society,
Nov. 14,  1854, Mr. Critchett  remarked, that with  Mr.  Bowman he had
reason to believe chloroform of great value in this operation. He had used
it also with much  advantage in performing  the operation for making an
artificial  pupil, in  children. Mr. Holmes  Coote  regarded it as a  bene-
ficial agent, but one which required to be used with circumspection.
  Just as we had  finished the  above notice of the use  of chloroform at
the Royal London  Ophthalmic  Hospital, wc observed in the Medical News
and Library, for  June, the report, copied  from a  recent number of  the
 London Medical Times and Gazette of a case of death from its adminis-
 tration in that Institution.   Although every precaution was taken, under
 the supervision of Mr.  Bowman himself, the patient, who was  about to
submit to the extirpation of the eye-ball, died.   The man was moderate-
ly  stout,  florid, and  healthy looking, and  had generally led a temperate
life.  At the autopsy, nothing was observed throwing light on the cause
of his death.
  The Gazette des Hopitaux, for  March  11, 1854, contains  a notice
 of two cases in which local  anaesthesia was  successfully obtained by
 means of Hardy's instrument, which consists of a caoutchouc reservoir
 of air, adapted to a copper pump, made to receive the  sponge  intended
 for the  chloroform.  A valve at one extremity permits the air to enter
 the instrument, which terminates in a caoutchouc tube.   The first essay
 was made by M. Nelaton, upon  a girl who  was suffering from abscess of
 the axilla,  and from a small wound upon the back of the wrist, both of
 which were extremely painful.  The first application of the  chloroform
 upon  the tumor in the axilla produced an insensibility which lasted three
 hours, during which time the  part could be handled  with impunity.   In
 the second case, M. Dubois plunged a knife into  the abscess, after tho
 employment of chloroformic  fumigation, and the  patient  declared  that
 she was  not conscious  of pain.   A simple substitute has been  proposed 
AMERICAN APPENDIX.
825
for Hardy's  instrument to which we have above referred.  The nozzle
of a common bellows may be removed, and just within its neck, a sponge
saturated with chloroform, or ether, be inserted  by means  of a strong
pin.  The nozzle being again applied, and the bellows brought into ac-
tion, the vapour  passes off from the sponge, mingles with the air in the
body of  the  bellows, and is forcibly directed to any part of the surface
of the body, required.
   In the  Gazette des Hopitaux, for February 21,1854, we have a clini-
cal lecture by M. Velpeau, on the subject of local anaesthesia.  He con-
siders  that it is impossible to produce this  effect by chloroform, because
this agent can act cnly through the medium of the  great  nervous cen-
tres, but in cold we possess an agent of real and energetic power.  With
the refrigerating mixture of four parts of pounded ice, and one of com-
mon salt, he  extracted-the nail in onychia, without pain.  When  applied
to other parts of the body, however, this method is not free from objec-
tions, and the improvements in  this plan of treatment mast have refer-
ence to its mode  of application.  By means of the evaporation of ether,
made more rapid by a pair of bellows, he has  succeeded  in producing
intense cold.  Mr. James Arnott has  published an article in the Lond.
Med.  Times and Gazette, March, 1854, p. 285, in which  he complains
that M. Velpeau has done him injustice in neglecting to mention his own
contributions on this subject; for he asserts, that in 1849, he made his
views known to the surgeon of  La  Charite, who expressed his approba-
tion.  In 1851, Mr.  Arnott had the politeness to show us his method of
applying cold for the purpose of benumbing  parts previous to the per-
formance of  a surgical operation, and of arresting the growth of malig-
nant or other vascular  tumors, and it certainly seemed most admirably
adapted to fulfil the object intended.   Mr. Arnott now maintains that
as there have been upwards of fifty deaths from the inhalation of chloro-
form, the use of the latter is no longer justifiable, and should  yield to the
application of cold.
  We  have tried the application of cold in two instances.   One was a
case of a small  mammary tumor ; in the other we removed the entire
breast.   Neither  of these patients  suffered from pain during the opera-
tion, but  the wounds  in  both  healed less speedily than usual.  Dr. J.
Mason Warren, has reported some cases in a recent number of the  Boston
Medical and Surgical Journal, in which he has resorted to the freezing
mixture as a substitute for chloroform.  We insert them in detail.
  The first  patient  was a young man having a congenital naevus, of  a
black color, and of large  size, situated over the inner part of the knee-
joint, below  the patella.   The tumor had remained of about the  size of
a dollar until within two years ; since that time a supplementary tumor
had appeared beneath the original, quite hard, extending into the adjacent
cellular membrane, and apparently  attaching itself to the synovial cap-
sule.   The whole tumor was sensitive in the highest degree, and at times
so painful as  to disable the patient from attending to business ; even the
contact of his clothes  producing suffering.   It was difficult to make  a
satisfactory  examination,  in consequence of his dread of the necessary
manipulations.  He  was  kept  in a horizontal posture for a few days
dieted, and an evaporating lotion applied, to prepare him for the  opera-
tion, which was done in the following manner.   Excision being objection-
  vol. hi.                      104 
826            NEW ELEMENTS OF OPERATIVE SURGERY.
 able on account of the relations of the tumor to the surrounding organs,
 equal parts of pounded ice and salt were enclosed in a small gauze bag,
 and applied to the tumor for four minutes, when the whole of it became
 congealed and of a white color, crackling under the touch.  A narrow-
 bladed knife was then introduced beneath the skin, and the tumor freely
 cut  up in every direction.  The operation was entirely painless; the
 patient sitting up, and watching its progress with much interest, although
 previously shrinking on the mere approach of fingers to the part.  The
 above  subcutaneous operation was repeated once or twice, and resulted
 in the absorption of  a large part of the tumor, and entire relief from the
 morbid sensibility.
   In a case of fascial paronychia, in which Dr. W. had recently employed
 the  same  method of anaesthesia, the painful incisions necessary to give
 exit to deep-seated pus were borne without shrinking, and he thought the
 cure more speedy than under the ordinary treatment.   The same fact
 was remarked by the patient, who was a medical man, and an acute ob-
 server.
   In one  or two cases of operation involving vascular tumors, Dr. W.
 had found it of  much service, during the progress of  the dissection, to
 apply the freezing mixture, and thus temporarily arrest the hemorrhage,
 so as to allow of a more satisfactory prosecution of the subsequent steps
 of the operation.
   In making the incisions in the congealed part, Dr. W. had  observed
 it necessary to  be rather more careful  to maintain a firm hold of the
 knife, and to employ more force  than  in  cutting  the integument  in its
 natural  condition ; otherwise the knife would slip off, and make  an in-
 cision at  some point  not intended : this is, however, avoided by a little
 practice.
  This difficulty in  making the incisions  through the integuments was
 strikingly manifested in the cases in our own practice, to which we have
 already alluded.
  It will be seen by  the following  paper read before the  New-York
Academy  of Medicine, October 4, 1848, that Dr. Mott attaches a very
high value to the use of chloroform in surgery.  G. C. B.]

Remarks on the Importance of Anaesthesia from  Chloroform, in
  Surgical Operations, Illustrated  by two cases.  By Valentine Mott.
  From the Transactions of the N. York Academy of Medicine, Vol. I.,
  Parti., 1851]                                                   '

  No event has occurred in the whole range of  the History of Surgery,
since the  discovery of the ligature by  Ambrose Pare, at all  comparable
to the anaesthetic influence of the aethers in surgical operations.  It
not only robs surgery of its greatest terrors, by  suspending sensibility
and all consciousness of pain during the performance of operations ; but
it enables us to  operate without the dread of any  shock to the nervous
system.
  We are abundantly  satisfied that now severe and formidable opera-
tions may be performed under the influence of those agents, which the
 most bold and adventurous surgeon would not have had the  temerity to
touch. 
AMERICAN APPENDIX.
827
    It is not my intention to examine into the history of the discovery of
 these remarkable agents, or the question of their  manner of acting on
 the human body.  For the present, we have had, perhaps, enough on
 these points,  at least until a more extended series of results shall be re-
 corded, to enable a purely legitimate deduction to be made.
    We view the discovery of the peculiar influence of these substances
 upon the brain and nervous systems of human beings, and the application
 of them to operative surgery, as the greatest present from chemistry to
 surgery that ever  was made, and a boon to suffering humanity of the
 most inappreciable value.  No imagination can conceive, and no tongue
 can tell, the  accumulated woes  it is destined to soothe and assuage.  It
 far outstrips  in its surgical  value to  the human race, any  discovery of
 which the present century can boast.
   •Pain  reduces all ranks to a level—it makes all men  cowards.  Some
 constitutionally and physically suffer very little from surgical operations ;
 while others, from  moral courage or  religious  culture, are enabled to
 endure great  bodily torture.  These however, form but a very small item
 in the great mass of the family  of mankind, and therefore deserve to be
 named only as exceptions to the great and general rule.
   The dread  of  suffering  has  prevented thousands  of human beings
 from submitting to necessary operations, and their lives  have been the
 forfeit.  Away with the  stupid  fanaticism that would inculcate the pa-
 tient  endurance of  suffering, when it can be  relieved.   It is a Divine
 admonition to soothe  the  sorrows, and to mitigate the pains of poor
 human nature.  And can any rational and intelligent being for a moment
 entertain a doubt as to  the propriety of using  a safe  and certain agent,
 to abolish for a time all consciousness of pain under surgical operations ?
   The object of the writer is only to extol the benefit of  chloroform, in
 cases in which the shock of the operation would in all probability be fatal
 without  its influence.   In the cases  which follow, I am free to say, that
 I would  not have  ventured to perform either of them, but for the influ-
 ence of this delightful agent.
   From  some experience  in operations, I am very  certain that they
 would both have perished long before the completion of the tedious and
 difficult  dissection which was involved in each of them.  Greater care is
 necessary to guard against haemorrhage after operations performed under
 anaesthetic influence, from the collapse that attends the full effect of it.
 More  time therefore has to be  given, before  the wound is dressed, in
 order that  the action of the heart and arteries may be fairly restored.
   Case 1.  A. B.,  a little  girl from Connecticut, aged between nine and
 ten years, of an excellent constitution and good health, was brought to me,
 in May 1848, with a cluster of large tumors in the neck, of different sizes
 from a man's  fist  to that  of a hen's egg, and even a black walnut, evi-
 dently making a most  extensive mass  of lymphatic glandular  tumors.
 The whole was not much  less in size than her head—reaching from be-
 hind her ear  to below  the  clavicle and under it—extending up to the
 larynx and trachea, crowding them to the opposite side, and pro ducing
 considerable difficulty of breathing.  It  had no feel of fluctuation at any
 part, but was elastic and without pain when handled.   It had been grow-
ing for nearly  five  years, and commenced in one small tumor, below and
about  the  posterior  angle of the lower jaw.   From this  arose  others, 
828
NEW ELEMENTS OF  OPERATIVE SURGERY.
 until the enormous enlargement took place,  as may be seen in the draw-
 ing which accompanies this, and  the morbid specimen  in bottle No. 1,
 which is carefully preserved.
   Various modes of treatment had been from time to time adopted, both
 local and general, popular and professional, without at any time produc-
 ing the least benefit.   The last that was tried were the  different prepa-
 rations of Iodine, locally and generally.  For nearly two years she used
 the hydribdate of  potassa as an internal  medicine, and  ointment of  the
 same was rubbed upon the tumors, alternated with the tincture, without
 the least benefit to the enlargement; on the contrary, the size continued
 to  augment gradually.
   In a state of despair, the  distressed parents brought her to me, to
 know if any other  treatment could be recommended, or if it was pos-
 sible to remove the whole by an operation,  with the least prospect of a
 favorable result.
   1 informed them that an operation would be  difficult  and dangerous,
 both from the unavoidable loss  of blood, as well as the  shock  upon the
 nervous system.  That I would not be willing to attempt it without she
 was put under the influence of chloroform.  This I informed them was the
 only thing that would justify an attempt to remove  the  whole  mass,  as
 the shock upon the nervous system would thereby  be completely prevent-
 ed.  That with this anaesthetic agent I felt myself warranted in perform-
 ing the operation.
  Inhaling the chloroform from a  handkerchief, she was  in a few minutes
 put under the full influence of this valuable agent.
  An incision was now made in  the longest direction of the tumor, begin-
 ning from above and behind the ear, and carried  obliquely downward and
 forward over the clavicle, near to  the origin  of the sterno-cleido mastoid
 muscle.
  As the external jugular vein  took its usual course over the tumor, I
 directed an assistant to compress it below the line of the incision to pre-
 vent the ingress of  air, and another to seize  with the forceps the upper
 extremity and place a ligature  upon it.  This was expeditiously  done,
 the vein being considerably enlarged.
  The first incision only went through the skin  and plasma  myoides,
 so as to divide the superficial jugular.   The  next cut the under layer  of
 the superficial cervical fascia.   It was now found that the sterno-mastoid
 was spread out very thin to some extent upon its outer margin  over the
 tumor.  This expanded state of the muscle might have led to the misap-
 prehension that the mastoid was not over it.  The integuments and  mus-
 cle  were now dissected off from the lower edges of the  incision, with a
view to get under it from below and on the  inner sides.  As soon as I
found the mastoid was passing  over the tumor, I  at once  anticipated a
difficulty in its removal.
  This was fully realized in the  subsequent steps of the operation   The
thin expanded muscle was now carefully detached  from the tumor after
which the  separation of it from all the adjacent  parts in front and'below
took place.  It was connected with the larynx and trachea in front  infe
norly to the inner surface of the clavicle—posteriorly to the whole extent
of the carotid sheath, and behind it passed under the trapezius muscle
  An isolated tumor the size of  a pigeon's egg was discovered below the 
AMERICAN APPENDIX.
829
 level of the clavicle, with apparently the deep  cervical fascia  over it.
 On passing a double hook into it and raising it, such was its depth and
 attachment to the subclavian vein, that I did not  think it prudent to re-
 move it.
   Although I was careful to cut through all the superimposed  tissues,
 so as perfectly to denude the  tumor before  attempting its separation, I
 do not think I ever met with such firm adhesions to the surrounding parts,
 except in malignant forms of disease.  Here and there only could  the
 handle of  the scalpel or fingers accomplish any  separation.  At every
 step it seemed as if  condensed and duplicated cellular  membrane with
 arteries were entering into every interstice and irregularity of the tumor,
 to add to the difficulty of its removal, and to prolong the operation.
   By practice and care, however,  and the influence of the chloroform, a
 most  invaluable  auxiliary  in  difficult operations, particularly  upon
 children, I finally succeeded in removing the enormous mass from all  the
 contiguous and  important parts, with perfect satisfaction to myself and
 safety to the patient.
   Many large arteries and veins were tied during the operation, but  the
 loss of blood was less than might have been expected, from the prompt-
 ness  and readiness  with which we secured  every bleeding  vessel.   To
 prevent secondary hemorrhage, we allowed the  anaesthetic influences to
 pass oft before dressing the wound.  As far  as my observation has gone,
 I would suggest this as a proper point of practice.
   When the free action of the heart and arteries had been restored for
 some ten or fifteen minutes, and no further hemorrhage  occurring,  the
 wound  was dressed with several stitches and adhesive straps, lint, com-
 press, and a moderately tight bandage around the neck.
   Most of the pain she complained of was a little smarting, which pro-
 bably arose from the stitches being introduced after the insensibility of
 the chloroform had passed off.  In the course of half an  hour after  the
 wound was dressed, four drops of  Majendie's solution of morphine were
 administered, and in the evening, being restless, two more were given.
   No  untoward circumstance occurred  after the operation, everything
 went on favorably, and the  wound mostly healed by the first intention.
 After three weeks from the operation, she left for the country.
   Case  11. was a beautiful little boy,  not quite  five years old, who
 about a year since was observed by his mother to have a small tumor or
 enlarged gland on the side of the neck, below the posterior angle of  the
 lower jaw.  It continued to  enlarge gradually, unaccompanied with pain,
 until it attained the  monstrous size delineated in the accompanying draw-
 ing, and contained in the jar before us.
   At its commencement, means were taken by  internal medicine  and
 local applications  to remove it.  They were faithfully persevered in  for
 months, without the least benefit;  indeed the tumor continued gradually
 to increase in size.
  It occupied the entire side of the neck, reaching from above and behind
 the  ear, to below the clavicle.  It went underneath, as well as lapped
 over the bone.  In front it passed beyond the centre line of the larynx
 and  trachea, crowding these parts to the opposite  side—and behind it
passed under the trapezius muscle.  The head was  considerably turned
from its immense size, to the opposite side.  The appearance of it ex- 
830
NEW ELEMENTS OF OPERATIVE SURGERY.
ternally was irregular and lobulated.  To the feel it was firm, and with-
out the least fluctuation at any point.
  The sterno-mastoid muscle  could be more distinctly discovered tra-
versing  the tumor  than  in the former case.   A number of veins were
also taking the course of the external jugular, instead of  one distinct
trunk.
  The operation was performed at one o'clock on the 26th of May, 1848.
He was previously put under the influence of chloroform.
  To command the whole tumor a crucial incision was made;  the first
extended from  behind  the  ear to the  clavicle—the second a  little ob-
liquely from the anterior to tho posterior edges, so as to  traverse the
longest axis of the whole  mass.  The incisions were  carefully carried
through  the  integuments, platisma  myoides,  and  under  layer  of
the superficial  fascia, so as fairly to denude  the tumor.  The dissec-
tion of the lower flaps was now commenced, tying veins and arteries as
they were divided.  At times it seemed for a short distance as if the sep-
aration would readily take  place ; but it was  soon  interrupted by firm
duplication of  cellular  membrane, and vessels  passing into the irregu-
larities, which  constantly embarrassed and prolonged the operation.  In
dissecting off the lower and anterior flap, the mastoid muscle was found
to be so  incorporated with the tumor, as to make it necessary to divide
it about two inches from the sternum and clavicle.
  This step enabled  me to get at the lower part just above the  clavicle,
but what next  appeared  was truly embarrassing, it was the deep jugu-
lar vein  running  through  the  tumor.   On the  inner part the  common
carotid was dissected perfectly bare for several inches from the tumor,
but the vein was so imbedded  in the mass that it was totally impracti-
cable to save it.
  For a time I left this part of the dissection, and turned my attention
to the separation  of other parts, hoping that I might be saved, perhaps,
the division of it, but there was no alternative  left.  I therefore seized
it with the  dissecting forceps, divided it, and a ligature  was instantly
placed below  the forceps!  The  upper end was readily compressed by
the finger of an assistant while the the dissection was continued.
  This being done,  I separated the lower portion of the tumor from the
remaining part of the deep jugular, the tumor here having destroyed by
pressure  the sterno-hyoid  and sterno-thyroid muscles.  It was  then de-
tached from the upper and inner edge  of the  clavicle, to the  anterior
margin of  the  trapezius  muscle.   Getting under it in this way, it was
more readily and safely detached from the parts below.   On dissecting
it from over the scalenus  anticus muscle, I carefully protected the phre-
nic nerve.  The posterior  and upper part was now dissected from over
the  mastoid process, and  turned down.   A portion of the tumor  was
now seen to pass under the mastoid muscle, and to become so complete-
ly incorporated with it, as to make it proper here also to divide the mus-
cle again, in order  to proceed with the  entire removal  of the whole
mass.  This was  done, leaving the  middle third of the muscle connect-
ed with the tumor.
  The anterior and  upper part was now separated from the side of the
pharynx  and  larynx, but  it was found after dissecting it from  the com-
mon carotid opposite the thyroid  and cricoid  cartilages, that  the deep 
AMERICAN APPENDIX.
831
jugular  could not be safely detached; we therefore  applied a second
ligature to it about an inch below the angle of the lower jaw, and divid-
ed below it, leaving  several inches of the  vein in the tumor, as may
be  seen in the preparation.  After this  the whole  mass  readily came
away.
  In the course of this dissection, tedious and difficult, more than twenty
ligatures  were applied to arteries  and veins.   The quantity of blood
lost during the whole operation did not exceed six ounces, several thought
four or five.
  After  removing  several small tumors from along  under the trapezius,
he was allowed to come from under the influence of the chloroform, be-
fore the  wound was  dressed, in order to favor  the bleeding  from any
arteries that might remain untied.  When all seemed safe, the wound
was closed with several stitches and adhesive straps;  lint compress and
roller moderately tight completed the dressing.
  As soon as the anaesthetic effect of the chloroform passed off, he com-
plained of a little smarting, but did not make any particular moan until
the stitches were  introduced.  In the course  of the first hour after the
wound was dressed, he took three drops of morphine to allay the smart-
ing—and in the course of the night two more.   No shock nor collapse
attended the going off of the chloroform, either  immediately or remote-
ly.   It was surprising and gratifying to witness  this wonderful fact, and
particularly  to some  of us accustomed to perform operations upon chil-
dren and  infants.   In both these cases the influence of the chloroform
was kept up for about an hour and a half.
  To be able to put the brain and nervous  system in such a state of in-
sensibility and quiescence, as to be totally unconscious, and then lastly,
after the loss of blood, and the completion of the operation, that there
shall not be any  collapse seen or felt by the patients, are among the
wonderful facts of the present age.
  He passed the night following the operation very comfortably, having
a full amount of sleep.   On the second day he took some aperients, and
every care was now  given to  prevent an undue  degree of inflammation.
No  fever  occurred  to require  any other treatment.  On the sixth  day
from the operation, the wound was dressed, and suppuration  being es-
tablished about the stitches, they were  taken away.  Most of the wound
was united by the  adhesive process;  the  ligatures came away in due
time, and the wound  regularly and kindly  healed.  When it had suffi-
ciently healed, care was taken by a bandage and position in bed, to pre-
vent the head from becoming awry.   Not only  was the distortion pro-
duced by the pressure  of the tumor before its  removal remedied, but
any further inconvenience from the loss of the middle third of the mas-
toid muscle.
  Thus have  terminated  two important surgical cases.  To me the re-
sult  has been  peculiarly gratifying.  In some respects they presented
peculiarities that must interest every surgeon.   Onelis, that they could
not have been borne without the anaesthetic influence of the chloroform.
The shock to the nervous system in  my opinion would have been fatal to
both.  The unavoidable duration of the operation, together with the loss
of blood, would have  deterred every prudent surgeon from attempting 
832
NEW ELEMENTS OF OPERATIVE SURGERY.
 the removal of these enormous masses, without the influence of this in-
 valuable agent.
   New York, June 5th, 1848.

   Since the preceding cases were drawn up for the Academy, it has been
 my melancholy  misfortune to have encountered a fatal one from the un-
 avoidable loss of blood attending the operation.  The tumor was identi-
 cal in character with the preceding, and similarly situated.   The removal
 of the mass, which was considerably smaller than either of the two be-
 fore  described, was difficult and tedious, as the description which follows
 will  clearly point  out.  Most of the  blood lost  was from veins, all of
 which  were enormously enlarged.  Several were tied previously to being
 divided, but what blood was lost, prevented  any reaction following the
 operation.   I do not believe he lost one tablespoonful of arterial blood.
   I am delighted to be able to state, that he recovered completely from
 the effect of the chloroform—that it acted as kindly  and as  favorably
 upon him as in any case in which I have used it, and that my confidence
 in it is not in the least changed.
   Case 111. I. M.,  a delicate boy, aged  five years and six months, had a
 lobulated tumor  upon the right side of the neck, which had been growing
 for about one  year before  he came under my notice.   It  commenced a
 little below the ear, and slowly and regularly  increased in size.  It ex-
 tended from above and  behind the lobe of the ear to the clavicle and
 under it—backward beyond the edge of the  trapezius, and in front over
 the larynx and trachea.  It had a soft elastic feel, but did not fluctuate
at any  part.  The  external  jugular  was enlarged and running over the
surface, as  also a number of other superficial veins distended far beyond
their natural size.   Two  large veins in front, opposite each side of the
trachea, which I suppose to have been the  superficial inferior thyroidal,
were nearly the size of my little finger.
  He  had  a constant hacking cough,  with  considerable difficulty of
breathing,  which were  steadily on the  increase, so as greatly to annoy
him during the day  and disturb his sleep at night.   He could only lie on
the affected side.  All his symptoms were  gradually on the increase, as
well as the  tumor, which led the family to seek  relief for the little suffer-
er.   All internal means and  external applications having been tried in
vain, the  attention of the parents and friends was  directed to a surgical
operation.
  This they were  informed  could be done, but they were at the same
 time  told that it  would be attended with great danger to his life, indeed
that he might die on the table; that my great  fear was from the loss of
blood, not the  shock of the operation upon his  nervous system.
  I told  them that I would not venture upon the operation without the
influence  of chloroform, and that by it all danger to the nervous system
would be obviated, but that no skill could protect him from the loss  of a
certain amount of blood, and that the effect of the loss of this was my
only fear.   This we repeated to them over and over, and that with  thia
fully understood, I was willing to perform  the  operation.
  With all these things fully before them, they  desired that the operation
might be performed.   It was accordingly done at 1 o'clock on the  22d
of August. 
AMERICAN APPENDIX.
833
  He was readily brought under the influence of chloroform, but the an-
aesthesia was less profound than in the two former cases.
  One incision was made behind, and a little above the lobe of the ear,
and carried down to the clavicle  in  the direction of the outer edge of
the sterno-mastoid  muscle.  It divided all  the structures  covering the
tumor, including the mastoid muscle, which was expanded to more than
double its width.  Nearly one half the natural width of the muscle was
left upon the outer side of the incision.   At the instant of the first incision
being made, a number of large veins were compressed and speedily tied.
When the bleeding was fully commanded, another incision was made a
little  below the middle of the first, over the longest  direction of the
tumor, towards the top of the shoulder, which also freely divided all the
superimposed structures.
  On dissecting off the loose tissues,  a large vein presented itself, not
much less than the  little finger, imbedded in the mass  about two inches
above the clavicle, and formed by an  assemblage of smaller veins.  A
needle and  double  ligature was conveyed under it, before it was cut.
The trunk below was carefully detached from the tumor, and turned with
the flap over the clavicle.  It continued distended with blood from the
several branches which went into it.
  The tumor being freed from its connections at this point, my next ob-
ject was to separate it from its attachments over the larynx and trachea.
On raising the inner half of the mastoid muscle, about an inch from the
line of the first incision through its middle, the deep jugular vein pre-
sented itself lying upon the tumor.   This was cautiously separated, tying
in the course of this dissection several small branches  with  two liga-
tures  a short distance from the trunk.  It was now drawn with the mas-
toid muscle towards the trachea, while the  tumor was separated from the
points underneath it. The deep jugular only was remaining over the tumor.
  The mass being  now dissected from over the  larynx and trachea, a
firm portion of it passed underneath  the right side of the upper bone of
the sternum and the sternal end of  the clavicle.   On  raising the inner
portion,  the fingers could be  insinuated partially beneath it, so that the
innominata could plainly be felt.  The other portion of it below the junc-
tion of  the  clavicle, and no small distance  along this  bone, seemed so
firmly attached  to  the  subclavian vein, that I deemed  it most prudent,
after a careful inspection, not to attempt to remove it.   It was therefore
cut across at this point, leaving a small portion  below the level of the
sternum and clavicle.  It was now seized  with a double hook,  raised up,
and a strong double ligature passed  around  it, near the middle, and tied
firmly.   From rising and falling during respiration, I believe it was also
attached to  the pleura.
  This done, the tumor was readily  removed.  Under  the mastoid mus-
cle, below and behind  the  ear, several smaller tumors were  separated
and taken away.  Also from under the edge of the trapezius behind.
  As  soon as these were removed, he was permitted to be relieved from
the anaesthesia of the chloroform.  From the great care taken to secure
everv bleeding vessel during the whole course of  the operation, not one
continued to discharge blood.   After waiting ten or fifteen minutes the
wound was closed with several stitches and  adhesive straps, and a light
dressing applied.
   Vol.  III.                  105 
834
NEW ELEMENTS OF  OPERATIVE SURGERY.
   A small quantity of brandy and water was given him, but he refused
 to take much.  He was now removed into bed, wrapped in blankets, and
 bottles of hot water placed  near his back and feet.   His skin was cool
 and moist—pulse very small and frequent.  He did not vomit after the
 operation, though whilst it was being performed  he had several turns of
 unloading his stomach.  He had been permitted to eat, contrary to my
 wishes, a short time before the operation was performed.
   In less than two hours from  the  operation  his  extremities became
 warm, with more action of the heart and arteries.   This in a short time
 was followed by restlessness, for which five drops  of morphine were
 administered.  In a short time he fell into a quiet sleep, for two hours.
 A profuse sweat followed, and  he  gradually sank and  expired in about
 seven hours from the operation.  He retained the full possession of his
 mind until the last moment.
   Long before chloroform was  known, or used, we have  met with cases
 in which death has followed operations, before the wound was dressed,
 and a few minutes after, and at other times in a few hours.
   As in this case there could be no shock upon the nervous system, his
 death,  in my opinion, was purely one from the loss of blood.   The quan-
 tity loGt has been variously estimated, but the average would be from
 eight to ten ounces.
  August 2Slh, 1848.

  We copy from the London Lancet, for October, 1853, the  following
 rules for the administration of chloroform, laid down by M. Baudens, of
 the Val-de- Grace Hospital,  Paris.
  1. Never go, intentionally, beyond the limit of cutaneous insensibility.
  2. The management of chloroform may be divided into three stages—
 before, during, and after the inhalations.
  3. Before: Counter-Indications.—Study the  patient's constitution ;
 find out whether there exists organic lesions of the heart or lungs ; these
 would be a counter-indication ; as are also  asthma,  aneurism, phthisis,
 chlorosis, anaemia, chorea, &c, and predisposition to  cerebral conges-
 tion.
  4. The patient's mind should be perfectly calm, and the  medical at-
 tendant should speak of chloroform as a boon, when  carefully adminis-
 tered.
  5. The patient should be wishing for anaesthesia, and have  full con-
 fidence in his medical adviser.  If he should  feel any  apprehension or
 gloomy forebodings,  chloroform should be steadfastly refused.
  6. Patients have in all times  died from the fear or pain of  operations;
 but the influence of fear is now no longer taken into account, and  chlo-
 roform accused of  all the mischief.
 ^ 7. Chloroform must never be given but for  operations of  a  certain
 importance, and patients should be fasting.
  8. Attention should be paid  to the  debility  which naturally  follows
 serious operations and considerable loss  of blood, for the  organism thus
loses its power of resisting the  influence of anaesthetic agents
 t 9. The operating-room should be of good dimensions, easy of ventila-
tion, and every article necessary in case  of danger should be at hand
  10. During the  Inhalation.—Chloroform should be administered in 
AMERICAN APPENDIX.                    835
 hospitals, by persons specially appointed for the  purpose ; and in town,
 by practitioners who make it their exclusive occupation.
   11. The quantity of chloroform given should be carefully measured,
 about fifteen minims being taken at once.
   12. The length of time during which the patient is inhaling should be
 counted upon the watch, as also the pulse and the number of respirations.
 Note should be taken of the force  and frequency of the pulsations of
 the heart; if the latter fall below sixty, the inhalation should be stopped.
   13. The patient should be in the recumbent position,  the head slightly
 raised by a pillow ; and should be given in  doses of  fifteen  minims, the
 time  between them being made gradually shorter.
   14. The  handkerchief should be first held at a  little distance, and
 gradually brought nearer the face, the patient being  spoken  to in a kind
 and encouraging manner.
   15. The latter should be.frequently asked, whilst he is being pinched,
 what is  done to him ;  and when he begins to answer with ill-humor, you
 pinch him, he is on the point of losing the faculty  of  sensation.
   16. As soon as he answer no more, feeling is abolished  ; the hand-
 kerchief should  immediately be taken away, and the operation begun,
 for we should never wait until muscular resolution is complete.
   17. Excitement, which often marks the first degree, is a mark that the
 handkerchief should be removed, far from being kept on, as is generally
 practised.
   18. The time has now come to watch the heart and the respiration.   On
 the slightest retardation, and if the symptoms of anaesthesia go on, or
 are even increased, means should be immediately taken to bring back the
 insensiblity to the first degree.
   19. When spasms of the larynx or much cough occur, if foam come to
 the mouth, if the pulse falls, if breathing becomes embarrassed, if there
 appears  any mark of syncope  or  cerebral congestion, the inhalations
 should at once cease.
   20. Slight struggling may be resisted, but violent excitement, and the
 exclamation  of " I  am choking," should be followed by the immediate
 removal of the handkerchief.
   21. For long operations the inhalations should be intermitted, and the
 chloroform may be resumed as soon  as the patient begins to sigh or move
 about.   Anaesthesia has in this manner been kept up  for one hour.
   In cases of asphyxia, produced by the administration of anaesthetics,
 artificial respiration must be at once employed.  If the surgeon neglect
 to resort to this immediately, he can expect but  little from  the  use of
 stimulants, frictions, electricity, &c.  By means of artificial respiration
 patients  have been restored when life appeared to be extinct.   In Febru-
 ary, 1855, we thus succeeded in resuscitating a boy, on whom we were
 operating for necrosis  of the tibia.   He was apparently dead, yet by the
 above method, conjoined with flagellation of the soles of the feet which
 was faithfully applied by Dr. David Wurtz,  of Ulster Co. N. Y. his  life
 was saved.
   It seems surprising that any surgeon familiar with the powers and dan-
gers of  anassthetics, should subject a person to their influence for a period
longer than is absolutely required to prevent pain during  the performance
of an operation, yet we almost daily witness cases in  which patients are 
836
NEW ELEMENTS OF  OPERATIVE SURGERY.
rendered insensible long before the preliminary arrangements have been
made.
  The purity of the  chloroform, or ether, should, of course, be well es-
tablished, before it is administered.   A valuable paper on the purity and
use of  chloroform, was read before the New  York Academy  of Medi-
cine, October 5th, 1850, by Dr. J. T. Metcalfe, who has had much expe-
rience in the administration  of anaesthetics.   This paper may be found
in the Transactions of  the Academy, Vol. I.,  Part I., and will well re-
pay a perusal.
                      ANUS, ARTIFICIAL.

   In a paper by Mr. Caesar H. Hawkins, read before the Royal Medical
and  Chirurgical  Society of London, February, 24th, 1851, we have an
analysis of  44 cases in which this operation had been performed.  It is
Stated by Mr. H. that when M. Amussat brought forward his memoirs on
this subject in 1839 and 1841, he could find but six cases, but that since
that  period it had been  performed  almost  every year, and there were
four persons  then  living in London, whose lives had been saved by its
performance.  Of the cases collected by Mr. H. 17 had been operated on
through the  peritoneum, and external to the peritoneum.  Ten had died
within  48 hours after  the  operation, and 21, within  the first 5 weeks.
One case, in which the  operation was performed for fistula, is omitted  ;
therefore, 22 only could fairly be  considered as having recovered from
the operation.  Of the latter 1 died in about six months from the opera-
tion, and only 9 were known to have survived the  first  year.   Notwith-
standing  this apparently unfavourable result, Mr. Hawkins showed that
life had in. every  case been clearly  prolonged.  In 17 cases the opera-
tion was performed on account of cancerous disease.   As to the compar-
ative merits of Littre's or Callisen's  method, it appeared that it is better
to operate externally to the peritoneum on  the right side of the body,
but the question was left  undecided as to the descending colon, so far as'
the much smaller  number of 8 compared with 20 cases, could settle the
point.  In the remarks  elicited by the discussion  of this  paper, it  was
observed in reference to the diagnosis of the  seat of obstruction, that Mr.
Moore, of the Middlesex Hospital, had hit upon a very simple method of
determining this  point.   A tube is  to  be passed some distance up the
bowel, and  an  injection thrown up.   On changing the position of the
patient and applying the stethoscope to the abdomen, if the fluid can  be
distinctly  heard to traverse the right side, it  may be inferred that the
large  intestines are free from  obstruction.   Now, we are  satisfied that
this test must be fallacious,  for the following reason.  Some years since,
we attended a patient who died on the 28th day after the occurrence of
complete obstruction of the bowels   At the autopsy, a morbid thickening
of the walls of the intestine was found on the left side occupying about
the junction of the middle with the  outer third of the transverse arch of
the colon.   Through this was an opening large enough to admit the bar-
rel of a small sized goose quill, but of a diameter not sufficient to allow the
passage of fecal matter.   Water injected, as recommended by Mr Moore 
AMERICAN APPENDIX.
837
would have passed, and  the fact been  detected  by the stethoscope  as
above indicated.

                         Anus, Imperforate.

  In  December 1853, we treated  a case  of imperforate anus, which
we  believe to  be  unparalleled.  At  the time it was placed under our
care,  the  child had lived for forty-nine days without a foecal  evacua-
tion.   Its  body was  excessively tumefied, and  appeared as if about
to burst at the umbilicus.  The anus existed, but a finger introduced
some  three quarters  of an inch, encountered firm  resistance, which
was perforated with  a trocar.   The opening, however,  thus  made
availed nothing.   With a  long-bladed, round pointed scalpel, I  pene-
trated nearly the depth of my fore-finger before I reached foecal matter.
A copious  discharge  now followed, the tumefaction of the abdomen be-
gan immediately to subside, the  vomiting, which for  days had been al-
most  constant, ceased, the child  nursed  well, and in  every  respect im-
proved.   About the third day slight  adhesions which had formed, were
broken  up with a bougie, after which there was no obstruction.   Some
six weeks  after the operation, the patient  was removed home, at a dis-
tance, and died very suddenly  the day after its arrival.  We have been
unable to find but one other instance on record in which a child had
lived  without relief for seven  weeks  after its birth.  In the text, our
author refers to a case in which the difficulty passed unnoticed until the
12th day.
  Dr. Lyell, of Dundee, reported to the Edindurgh Obstetrical Society,
May 12, 1847,  a case of imperforate  anus, in which the child lived for
12 weeks without any foecal outlet but that of the mouth.   (The report
of Dr. L's case, may be found in  the Monthly Journal, 1847, p. 137.)
  In January, 1854, Mr. Fergusson performed  Amussat's operation of
opening  the descending  colon in the  left loin, in a case  of  imperforate
anus where no evidence existed that the bowel came near to the perine-
um.   The infant was nine days old  at  the time of the operation, and suf-
fering much, the  belly being  swollen and tympanitic.   The intestine
was easily reached and a copious gush of faeces followed.   The patient,
at last account, was doing well.   After the reading  of this report to
the London Pathological Society, at its meeting on the 7th of February,
1854, Dr. Crisp  and  Mr. Adams  expressed their preference  of this
method to pushing a trochar into  the rectum from  the perineum, but
we think the result in our own patient shows that by persevering with the
knife, not the  trocar, we may succeed even  under very  desperate cir-
cumstances.  In the discussion above referred to, Dr. Ramsbotham spoke
of the usual unsuccessful result of  these operations, and remarked that
where the sphincters are wanting, the chances must be very small.  Messrs.
Partridge, Overbury, and Shaw, on the other  hand, referred to instances
in which the patients had survived many years, and in the case mentioned
by Mr. Shaw, at first there was a constant and involuntary discharge of
faeces, but  the  orifice  soon contracted, and the patient was frequently
troubled with constipation, which, however, was easily relieved by ene-
mas.  This patient, perfectly  recovered,  and became a stout, healthy
looking boy (Lond. Aled. Times and Gazette, Feb. 1854, p. 171.)  Even 
838
NEW ELEMENTS OF OPERATIVE SURGERY.
when the icrmination  of the rectum  is far distant  from the anus, as in
the case  reported in Langenbeck's " Surgical Bibliotheca" or as was the
case in ray own patient, the rectum may be pierced with the pharyngot-
ome, or the long bladed knife used by ourselves.  Mr. Ashton remarks,
( Diseases  of Rectum, London, 1754, p. 334) " I imagine few English
surgeons would propose to adopt the operation of Littre or Callisen for
opening  the descending colon,  much  less putting into practice that of
Dubois, of opening the sigmoid flexure of the colon, and passing a strong
probe through it towards the perineum, by pressure  rendering the end
prominent, if possible, then cutting down upon it."
  Mr. Teale, in his article on Intestinal Fistula, published in Costello's
Cyclopedia of Practical Surgery, has collected the reports of 18 cases
in which an artificial anus was made in'the groin on account of  congeni-
tal imperforate anus.   In seven of these it is said to have been  success-
ful.  In some  cases life can  be prolonged in no other mauner.   In the
instance  above referred to, where  the patient survived for  12 weeks,
with no outlet for the faecal  matter but the mouth, it was found at the
autopsy, that the colon terminated in a cul de sac, floating loosely among
the other intestines in the umbilical region, and in such cases, of course,
there is no alternative  but to  open the  colon in the right groin, and not
in the left,  as was done by Mr. Fergusson.
                   BLADDER, PUNCTURE  OF.

  On the 13th of April, 1852, a paper  by Mr. Edward  Cock, of Guy's
Hospital, was read before the  Royal Medical and  Chirurgical  Society,
in which he brings forward some 40 cases, to show that puncture by the
rectum is a safe and simple operation for the relief of retention of urine
or facilitating the cure of permanent stricture.  In all of the cases col-
lected by Mr. Cock, the operation  was entirely successful, so far as the
relief and the absence of any  ill consequences were concerned.   Seven
deaths occurred, from various causes connected with the previous suffer-
ings of the patients, such as arose from diseased kidneys, inflammation
of the bladder, &c.   In many of the cases, Mr. Cock believed the opera-
tion materially tended to  the restoration  of  the  patient, with a less
amount of suffering, and at the same time more speedily and effectually
than could have been effected in any other way.   As is well known Mr
Liston condemned puncture by the rectum.  In cases of prostatic en-
largement he regarded it as wholly  inadmissible, preferring forcep cathe-
terism in such cases.  The question may  fairly arise whether a perfora-
tion made in this  manner is less dangerous  than that made by a sharp
pointed trocar    Although sanctioned  by so high an authority as Sir
Benjamin  Brodie we think if  called upon to submit to either of the op-
erations, in case of prostatic enlargement wo should select puncture by
the  rectum.  But would not the puncture  above the pubes be infinitely
superior to either ?   It is said that the  perforation of the obstruction by
the  skilful use  of the catheter is attended  with but little risk of harm
kit  it is no easy matter in some of these  cases with the  catheter, to make
 -s skillful perforation.   Let us  examine the following statistics  by
t
thi 
AMERICAN APPENDIX.
839
Mondiere,published in the Revue Medicate, for April, 1841.  The table
embraces 92 cases.

Puncture.       No. Cases  Success Fistula  Infiltration Abscess Hemorrhage  Death
Perineal        9        6      10       0        1         1
Recto Vesical  28       19      3      3       1        0         2
Suprapubic   55       49      0      0       0        0         6
Total          92       74      4      3       1        1        9

   From this it appears that the recto-vesical is the least fatal of the three
methods, but is more frequently followed by  infiltration, fistula, and ab-
scess.   Prof.  Gross, in his most valuable work on the  Urinary Organs,
p. 315, relates a singular  instance of supra-pubic  paracentesis  of the
bladder, in  which the puncture,  after having  been  perfectly healed, re-
opened at the end of fourteen years !   The  patient was laboring under
constitutional exhaustion of which he died.   For four weeks previous to
his death urine was discharged through the supra-pubic opening.   From
what he has  seen of retention  of urine, Prof. G. is satisfied that punc-
ture of the  bladder is rarely, if ever necessary,  and he quotes from Mr.
Liston's Elements, fyc, to show that Mr. L. had never  punctured the
bladder but once.   However, from the remarks made by Mr. Solly, dur-
ing the discussion of Mr. Cock's paper, it would  appear that Mr. Liston,
previous to his death, had modified his opinion as regards the recto-vesi-
cal operation, for Mr. Solly states that he was present when that distin-
guished surgeon  performed it a few months before he died.   As to the
objection that fistula is liable to  follow this method, Mr. Cock states that
in 24 cases  in which he himself  has operated, no instance has occurred.
(Lond. Lancet, Am. Ed. June,  1852, p. 474.)
  Another method has  been proposed and practised, its object being to
diminish the risks and inconveniences following the three modes already
mentioned.  Dr. Brander  of India, punctures the bladder through the
symphisis pubis.  He employs a  flattened trocar which is plunged directly
through the centre  of  the  fibro-cartilaginous substance, uniting these
bones,  into the bladder.  The advantages claimed for this method, are,
its  facility  and immunity  from danger, as it is impossible to wound the
peritoneum, even though the bladder remain  below the pubis.   There is
little or no risk of effusion, should the point of the canula  slip out of the
bladder, since the walls of this  organ glide  upon each  other to such an
extent during its contraction as to produce a valvular closure of the
opening.  Dr. Brander's memoir was published  in the Transactions of
the Medical and Physical  Society of Calcutta, 1838, but a particular
notice  of it, together with some experiments on the subject, by Mr. H.
T. Chapman, may  bo found in  the  London  Lancet, July 10, 1852, or
Ranking's  Abstract, No. 16, p. 158.   Dr. Leasure, of New Castle, Pa.
has  reported a successful case, according to  this method, in the Ameri-
can Journal of Medical Sciences, April, 1854, p. 403.
  Dr.  F. D. Lente, recently one of the house surgeons of the New York
Hospital, in a  paper on  "Perineal Section for Stricture of the Urethra,"
published in the March number, 1855, of the N.  Y. Journal  of Medi-
cine, Sfc, states, that during his connection with that Institution, from 
840
NEW ELEMENTS OF OPERATIVE SURGERY.
1847 to 1851, the  practice of puncturing the  bladder for retention of
urine was not resorted to in a single instance, but that relief was always
attempted by the perineal incision.

              Bladder, Extraction of Foreign Bodies.

  M. Leroy de Etiolles addressed a communication to the Academy of
Medicine, at its session of March  14th, 1854, in which ho describes an  N
instrument he has successfully employed in the extraction of* hair-pins
from the bladder.  The following figures convey an accurate idea of the
form of the instrument, and of the manner in which the hair-pin is seized.
  The description of these(instruments may be found  in the Gazette
Medicate, March 18th, p. 167, and the illustrationsin the same journal for 
AMERICAN APPENDIX.
841
March 25th, 1854.  By one of these instruments, as will be seen, a com-
mon pin may be extracted.  M. Leroy  has operated in three cases in
which a hair-pin has been introduced into the bladder.
                         BRONCHOTOMY.

  The most important contribution recently made on this subject is, un-
questionably, Professor Gross' Practical Treatise on Foreign Bodies
in the  Air Passages, Phil. 1854.   Prof. G. highly extols the use  of
chloroform in the operation of bronchotomy, and declares that he would
not omit it in any case ; " for it is difficult to conceive of one where it
would  be inadmissible, and it is  hardly possible  to recommend it too
highly or too strongly to the- notice  of the profession."—p.  239.   For
the purpose of extracting foreign bodies from the  air-passages, after the
operation, Prof.  G.  gives the preference to the instrument represented in
the following figure, and jvhich is of  his own invention.
   These forceps are composed of silver, and are a little more than eight
inches in length.   The handle is  considerably  curved on the  flat, and
has two large rings for the thumb and  finger.  The blades, round and
very slender, are five inches long, and terminate in fenestrated extremity,
nine lines in length, by three in width, the outer surface  being smooth
and  convex, the inner flat and slightly  serrated.    From the  peculiar
arrangement of the handle of the forceps, the blades when shut, partial-
ly overlap each other, and thus occupy the smallest possible space in the
trachea.  The whole weight of the instrument is a little over five drachms.
" The great advantages of this instrument are, first, that, being very long
and  slender, it may be used with equal  facility as a probe and an extrac-
tor ; secondly,  that, being composed of silver, it may be bent at any point
and  in any direction, according to the  pleasure of  the  operator; and
thirdly, that it is so exceedingly delicate that  it cannot  possibly serious-
ly impede the passage of the air, during the attempts which are  necessa-
ry to explore the wind-pipe for ascertaining the  precise situation of the
foreign substance."
  Professor Gross' treatise, as already  stated, is devoted to the subject
of foreign bodies in the air passages, but his work abounds in such prac-
tical information in reference to the operation of bronchotomy,  whether
performed  for  the extraction  of foreign bodies, or  any other purpose,
that we  would strongly  recommend  its  persual to  those who  may be
called upon to  undertake these operations.  Our  limited space prevents
us from quoting more fully, as we would wish, from its pages.
  More than half  a century has passed since Dr. Physick proposed to
  vol. in.                      106 
 842           NEW  ELEMENTS OF OPERATIVE SURGERY.

 open the trachea in cases of hydrophobia, to save the  patient from the
 suffocation caused by spasm of the glottis in this disease.   His views
 upon this subject were published  in the New- York Medical Repository,
 Vol. V., Xo. I; and in the same Journal for August, September and Octo-
 ber, 1803, there is a communication from Dr.  Rush, giving an  account of
 the  autopsy  of the body  of a  person  who died from hydrophobia, in
 which the orifice of the  glottis was found completely closed,   In this
 instance preparations were made for tracheotomy, but "  such a  change for
 the worse took place," that it was not performed. Of late, Marshall Hall
 has  strongly  advocated this operation  in the laryngismus which occurs
 in other diseases, such as epilepsy, tetanus, infantile and  puerperal convul-
 sions, which  may terminate in  cerebral congestion, asphyxia, &c.  We
 copy from the London Lancet, for November, 1852, the following synop-
 sis of the cases in which  he  considers this operation to  be indicated:

             Table of  Cases requiring Tracheotomy.

   I.  Cases of Paralytic  Laryngismus;      •
     1. Apoplexy of Inorganic Origin ;
     2. Coma after Epilepsy  ;
     3. Deep Intoxication ;
     4. Severe Narcotism;—each combined with formidable stertor threat-
 ening life.

   II. Cases of  Spasmodic Laryngismus;
     1. Epilepsia Laryngea,  threatening life or intellect;
     2. Epilepsy with Torticollis,  with  the danger of suffocation ;
     3. Infantile, and
     4. Puerperal Convulsion ;
     5. Hydrophobia;
     6. Tetanus;
     7. Pertussis threatening Convulsion or Hydrocephalus;
     8. Laryngitis;
     9. Ulceration of the Larynx  ;
   10. Certain Cases of  Cut-Throat;
   11. Diseases adjacent to the Larynx, as
         1.  Tumour,
         2.  Aneurism,
         3.  Cynanche Tonsillaris,
\        4.  Scarlatina, Variola,—with paroxysms of Laryngismus ;
     12. Choking, from
         1.  A Foreign Body in the Larynx or Trachea ;
         2.  A Foreign Body in the Pharnyx ;
         3.  A Mass of Food in the Pharynx ;
         4.  Inhalation of Acrid Vapour;
         5.  The Attempt to drink Boiling Water,
         6.  Swelling following the Attempt at Suicide by Strangula-
              tion, <fec,  &c.
   13. The Poisonous Effects of Strychnia, &<$., threatening suffocation.
   III. Cases of Permanent  Laryngismus;
         1.  (Edema of the Glottis ; 
AMERICAN APPENDIX.
843
         2. Laryngitis ;
         3. Other Diseases of the Larynx, or
         4. Of the adjacent Tissues.

To these may perhaps be added—

  (IV.  Cases of Asphyxia;
         1. Drowning;
         2. Hanging;
         3. Suffocation from Mechanical Causes,
         4. From breathing Irrespirable Gases, &c, &c.;—the object
               being efficient artificial respiration.)

  As yet we have not sufficient data  to determine whether  Dr. Hall's
sanguine expectations are likely to be realized from this operation in
the treatment of epilepsy.  Dr. Radcliffe  published  a  summary of the
cases thus treated, in the London Lancet for  May, 1853, and he asserts
that tracheotomy is of questionable utility in any form of epilepsy.   We
quote his remarks upon this point:
  " On looking over these cases, (seven in number) therefore, one con-
clusion is inevitable—namely, that severe  fits have followed the opera-
tion—fits in which the tongue has been bitten, and one fit in which death
has happened.  Almost uniformly  the convulsions have been as bad as
ever.  As judged, therefore, by the results of the cases in which  it has
been  practically tested,  the utility of tracheotomy  in  epilepsy would
seem to be extremely doubtful; so doubtful  indeed,  as to  render it a
matter of paramount and imperative necessity to pause and ponder well
upon the evidence before again resorting to  it, and this  all the  more,
because it is by no means certain that the remedy is not more dangerous
than the disease,  and because the inevitable result of the operation is to
convert the patient into a dumb, whistling wretch, whose every breath is
an annoyance to himself and others."  We think the latter  observation
unfounded, but as to the  merits of  the other objections brought forward
by Dr.  Radcliffe, more  extensive  experience  is required  to  form an
opinion.
  In a Lecture delivered before  the  Medical  Society of Virginia, De-
cember 3, 1853, Dr. Marshall Hall made the following comments upon
the cases in which this operation had at that  time been performed:
  " Every  case in medicine is a case for  the individual  practitioner in
that  individual  case.  If in  future you should meet with a case of epi-
lepsy, if this be complicated with laryngismus  spasmodic or paralytic,
if on this you believe that danger  to life or mind or limb depends, you
will  of course weigh all  those circumstances against the formidability
of the operation of tracheotomy ; and if you so judge that this remedy is
incomparably of less severity  than that danger or malady,  you will of
course perform it.  The remedy is  certainly heroic enough ; but in  some
cases the malady is also herculean.  I would bias no one, but I  invite
every one to examine well and judge for himself.   In the first place, the
diagnosis  must be  duly  instituted;  there must be  laryngismus; the
danger  must be  duly appreciated, and  it  must depend on this laryn-
gismus ;  it must be considerable to justify the operation, and it must de
pend on the laryngismus  to render that operation appropriate. 
844            NEW  ELEMENTS OF OPERATIVE SURGERY.
  A considerable number of cases have occurred, in which tracheotomy
has been instituted in epilepsy.   In the first, the success was immediate
and perfect;  life was instantly saved, and the farther fits prevented.  In
several, a failing mind  has been  restored, and the patient has returned
to business  after relinquishing it from incapacity.   Two cases have
occurred in this country ; one, under the care of Dr. John Neill, of Phil-
adelphia ; the other, under that Dr. Herrick, of Chicago.  I have pub-
lished these, with a commentary, in the London Lancet  for September,
1853.   Although the ultimate event was fatal in  both, yet in both  the
immediate relief afforded by this  operation was the most promising, and
both those  eminent practitioners state their unreserved approbation of
the use of the remedy in the  cases in question."
  The cases quoted by Mr. Lawrie in his Statistics of  Tetanus, published
in the  Glasgow Medical Journal, for January, 1854, (see also,*  Assoc.
Aled. Journ. Jan. 6, 1854, p. 19,) do not  lend much encouragement to
the practice above proposed ; but from the temporary benefit afforded, we
may perhaps in other instances prolong life, and give to the remedies em-
ployed more time to produce their effects.   " The idea," says Mr. L., " of
opening the larynx or  trachea  in cases of tetanus, when asphyxia is a
prominent symptom, is not  new.  Many years ago, I strongly urged it
upon  a  patient who would not submit  to it, till the last fatal  paroxysm
set in ; she was dead before the operation was finished.   So far as I know,
my friend and colleague, Dr. A. Buchanan, was the first to perform it
as a curative in the earlier  stages of the  disease, without reference to
the  urgency  of the dyspnoea.  I performed it in  one case, but the dis-
ease was too acute and rapid to  hope for benefit from any remedy.  It
was had recourse to by Dr. Buchanan in the case of Lamont, a power-
ful seaman, while his  strength was still good.   He seemed much relieved,
the  spasms  did  not  appear  to extend  below the opening in the larynx,
and for some hours  hopes  of success were entertained, but  death  oc-
curred on the second day.   My friend and late colleague, Dr. Hunter,
opened  the larynx in a case which  occurred in the  hospital  since  the
table was drawn up.  The case was very acute, deglutition and respira-
tion being very difficult.  The operation seemed to succeed to the extent
of enabling  the  patient to swallow with  comparative  ease,  but in no
other respect was it even palliative.   I sat for some time beside the poor
man, soon after the  operation, and next day not  long before  his death,
and never witnessed greater agony.   He  died  in about 24 hours after
the performance of the operation."
  M. Maisonneuve, in September, 1853, performed  tracheotomy in a case
of tetanus.  Respiration had ceased,  the  patient being completely as-
phyxiated, but returned to life.   He died however that same evening.
  During the month of April, 1854, we were invited by a professional
friend to see a case of tetanus of some seven days standing.  The patient
was supposed to be improving, but in an effort to swallow a small quantity
of milk, he was instantly seized  with symptoms of suffocation, and died
in less than three minutes.   Seeing the imminent danger, we immediately
urged the operation of  tracheotomy, but to this the physician was reluc-
tant to consent until  respiration had ceased, when handing me the knife
I at once made a free incision into the trachea and established artifical  res-
piration, but it was soon apparent that our patient was dead. Could I have 
AMERICAN APPENDIX.
845
obtained permission  to operate one minute sooner, I have but little doubt
that life  would have been at least prolonged.  At any rate, in another
case of tetanus we shall propose the operation at an earlier stage of the
disease.   We believe that tracheotomy has likewise failed in a case of
tetanus, in which it was tried at the New-York city Hospital.  There is
one consolation left to the surgeon after the  operation, in cases of this
kind, and that is, the patient cannot die, before his eyes, from spasm of
the glottis.  *
  The only report of a case of puerperal convulsions treated by trache-
otomy  that has come under our notice, is the one communicated by Mar-
shall Hall to the Editor of the Buffalo Medical Journal, for May, 1854.
The case occurred to some practitioner in the country, who furnished the
details to Marshall Hall.  We insert the report unabridged.
  Mrs. G----a  delicate  woman, aged 29, was roused from her sleep at
3 A. M.  March, 7, by the  escape of the liquor amnii, which was the first
notice  she received of the commencement of labor, having arrived at the
full period of  a first pregnancy ;  all seemed to progress favorably until
about half-past nine; vomiting, yawning, and headache being then pres-
ent.  During this period  her countenance was unusually pale, but these
symptoms did not create  alarm in the mind of the gentleman in attend-
ance, until 9.30,  when a most severe  and  sudden  fit of convulsions at-
tacked her, which lasted about an hour, in which the face ivas very livid,
and suffused, and the veins of the head and neck much  distended, the ca-
rotids beating most violently.   The general  convulsions and contraction
of the  countenance were of the most fearful description.  On my arrival,
a vein  in each arm was opened, and finding the fits returning with great
violence at short  intervals, I resolved to empty the uterus as speedily as
possible, and I practiced craniotomy and removed the foetus.   The pla-
centa was expelled,  by uterine action, in about five minutes ; there was
no haemorrhage ;  and the  convulsions subsided.   Consciousness was re-
stored, and some gruel taken.  She remained in this state for  about an
hour, when the convulsions set in again most violently.   The jugular vein
was opened, as well as a vein in the arm ; the hair cut off, ice applied to
the head, hot applications to the feet, cataplasms, &c, &c., &e.   Tcre-
binthinate enemata were administered ; still  convulsions returned, and
I could but reflect upon the parallelism (to my mind) between  this case
and the epileptic cases in  which Dr. Marshall Hall has recommended the
adoption of tracheotomy ;  and as asphyxia was threatened every moment,
and the constriction of the  neck, and distended  veins, <fcc, made each
attack so perilous, I resolved  to operate, though in the middle  of the
country, and without the  usual appliances for so delicate an operation,
which, also, was  rendered more difficult by  an enlarged thyroid  gland.
I, however, converted the silver tube  of my caustic case (the end being
removed) into a tracheal pipe  secured by a tape, and with the aid of the
few things my pocket case  contained, in addition to my penknife, I accom-
plished my purpose.  Not a dessert-spoonful of fluid  was lost, and the
moment the trachea was opened, the relief was apparent in the counten-
ance, which never  after  became in the least livid, neither did the veins
ever become  distended.   The  fits did not, however, cease, but they be-
came less frequent, and less violent, and it was evident  that there was a
marked diminution of suffering to the patient, and time given for the
administration of remedies; which,  however, ultimately proved of no 
846
NEW ELEMENTS OF OPERATIVE SURGERY.
avail, for the patient sank about noon the next day, having survived de-
livery about twenty-four hours.
  " I should mention that her case was complicated with bronchitis, hav-
ing, a fortnight before, taken cold, and been coughing a good deal, and the
quantity of Wco-purulent secretion discharged from the  operation was
very great.   There is also another circumstance with which I was struck:
the absence of convulsions during the time the cataplasms were smarting
(while consciousness remained) as well as during the pain of the oper-
ation, and the passage of the child and after-birth into the world.  The
first  convulsion  immediately followed a digital examination.  Her ner-
vous system had received a great shock about twelve  days before, which
had affected her very much.   The convulsions ceased about 1 o'clock in
the morning, and a state of coma continued to the last."
  Marshall Hall adds, that it is to be regretted the orifice made into the
trachea was not of more ample dimensions.  To prove availing, it should
be sufficient to remove absolutely all laryngeal dyspnoea during the par-
oxysms of convulsions.
  It should also, he observes, have been performed earlier, perhaps in-
stead of the second blood-letting.
  Tracheotomy in croup seems to  be regarded  with  but  little  favor by
many British and American surgeons, whilst the French boast of consid-
erable success.   Up to 1850, M. Trousseau, as  is well known, claimed
in his practice,  one recovery in four operations, and  had then  resorted
to tracheotomy  in 135 cases.   Since 1850, he states,  that he  has had
seven recoveries in seventeen operations, and attributes  this increased
success to his employment of the double canula, and  preservation of the
warmth and moisture of the inhaled air by meaus of  a  cravat which en-
velopes the neck, and of charpie covered with waxed silk, by which the
drying up of the mucous in the trachea and bronchia is prevented.  He
prefers tracheotomy to  laryngo-tracheotomy.   For further details con-
nected with his practice, we would refer the reader to the recently pub-
lished works on the diseases of children, by MM. Rilliet and Barthez,
Valleix, Bouchut, and Drs. Churchill,  Condie, and Meigs.
  M. Guersant  seems to  have had  an equally extensive experience with
M. Trousseau in tracheotomy in croup.  In the Memoires de la Sociele
de Chirurgie de Paris, tome troisieme, 1852-3,  we  learn that he has
operated in 150 cases since 1834,  but that his  earlier operations were
very unsuccessful.  His later operations, however, have  been  followed
by much  more  gratifying results.   In 1850, of  forty cases in  private
practice, eleven recovered ;  and of twenty in hospital practice, seven
Were successful.  During 1851, of thirty-one operations at the hospital,
thirteen were successful.   He refers to one of the immediate  ill conse-
quences of the  operation, not generally noticed, namely, the escape of
food by the opening in  the trachea, during deglutition.   The child may
thus perish from inanition, unless fed  with the oesophageal tube, passed
through the mouth or nares.  By entering  the air-passages, the morsels
of food may likewise excite a rapidly fatal inflammation.  The complica-
tion  above noticed, was observed  in three of  the thirty-one cases which
came under his  care in 1851.  The mortality following  tracheotomy in
croup stands in striking contrast with that for  the  removal of foreign
bodies ; in twenty-nine cases of which, collected by Dr. H. H.  Smith,
(Operative Surgery, p. 262,) only one died. 
AMERICAN APPENDIX.
847
   One word  in reference to  the  manner in which tracheotomy is per-
formed by Dr. Hall.  In opening the trachea, the skin only is cut, the
trachea being pierced with an instrument which, like the dissecting for-
ceps, is brought to a point, and  may then be so dilated as to admit of the
introduction of the wire cage which he employs as a substitute for the tube.
He asserts that the tissues readily yield to this stretching.  According to
this method there can be but  little risk of wounding the  adjacent blood-
vessels.   A wound even of a large vein may prove fatal from the entrance
of air, as occurred in the case  reported by M. Heyfelder, in Das Chi-
rurgische und angenkraken Clinicumdes Universitat Erlangen,18±5-4:6.
   Mr.  Erichsen, in his Science  and Art of  Surgery,  Lond. Ed., p. 701,
has given  an illustration of a tracheotome  recommended by  Mr. H.
Thompson, which is intended to obviate the dangers and  difficulties »f
the old operation.  The instrument resembles a curved  forceps, with
lancet-shaped points, by means of which a puncture is made transversely
through the skin  and cellular tissue, and   between the first and second
rings of the trachea, so that the cartilages are not injured.  The blades
once introduced they are held by the left hand, and a screw attached to
the handle is gradually  turned, and the contiguous structures  dilated by
the separation of the blades, sufficiently to admit the introduction of a tube.
A similar  instrument is now  manufactured by  Mr. Tieman, the well
known surgical instrument maker of Chatham street.
                          CARCINOMA.

   At a meeting of the American  Medical Association in 1851, a Com-
mittee was appointed to report on the  results of surgical operations in
malignant diseases.  Prof. Gross, was selected as Chairman of this Com-
mittee, and he  immediately engaged in  such  steps as should secure, as
far as possible, the desired information.  The  results of his labors ap-
peared in the  Transactions of the Association, Vol. VI. 1853, and are
such as might have been expected from his well known abilities.  He
has furnished us with the opinions of the  most celebrated surgeons in
Europe or America, but we can quote only the  general conclusions.
   " From the facts and statements which have now been presented," he
remarks," embracing the opinions of many of the most intelligent, ex-
perienced, and  distinguished practitioners in  different ages, and in dif-
ferent parts of  the world, the following conclusions may be  legitimately
deduced:—
   "First. That cancerous affections, particularly those of the mammary
gland, have always, with a few rare exceptions, been regarded  by prac-
titioners as incurable by the knife and escharotics.   This opinion, com-
mencing with Hippocrates, the father of medicine, has prevailed  from the
earliest records of the profession to the present moment.   Nature never
cures a disease of this kind, nor can this be effected by any medicine or
internal remedies known to the profession.
   " Second.  That excision, however early and throughly executed, is
nearly always, in genuine cancer, followed by a relapse, at a period vary-
ing from a few weeks to several months from the time of  the operation. 
 848            NEW ELEMENTS OF OPERATIVE SURGERY.

   " Third.  That nearly all the practitioners, from the time of Hippo-
 crates to the present day, have been and are still averse to any operation
 for the removal of cancerous  tumors  after  the establishment of ulcera-
 tion, rapid growth, firm adhesions, organic change in the skin, lymphatic
 invasion, the cancerous dyscrasy, or serious constitutional  derangement,
 on the  ground that, if  had recourse  to under  these  circumstances, the
 malady  almost inevitably recurs in a very short time, and  frequently
 destroys the patient more  rapidly than when it is permitted to pursue
 its own course.
   " Fourth. That in all cases of acute carcinoma, or, in other words, in
 all cases of this disease attended with very rapid development and great
 bulk of the tumour, extirpation is improper and unjustifiable, inasmuch
 as it will only  tend to expedite  the fatal result, which, under such cir-
 cumstances, always takes place in a very short time.
   " Fifth.   That all operations performed for the removal of encephaloid
 cancer and  its  different varieties, are  more  certainly followed by rapid
 relapse than operations performed upon scirrhus or hard cancer.
   " Sixth.   That in nearly all  operations for  cancerous  diseases  hitherto
 reported, the history has been  imperfectly presented, being deficient in
 the details which are necessary to a complete and thorough understand-
 ing of the subject in each case.   This remark is particularly true in re-
 ference to the diagnosis of the malady, the  minute examination of  the
 morbid  structure, and the  history of the case after the operation, as to
 the period of relapse, the  time and nature  of the  patient's death, and
 the result of the post-mortem examination.
  " Seventh. The cancerous affections of the lip and skin, now usually
 described under the name of cancroid diseases, are less liable to relapse
 after extirpation  than  genuine cancerous  maladies, or those which are
 characterized by the existence of the  true cancer-cell and cancer-juice,
  " Eighth. That although practitioners have always been  aware, from
 the earliest  professional records, of the  great liability of cancer to re-
 lapse after extirpation, a great majority of them  have always been,  and
 still are, in  favour of operating in the early stage of the  disease, espe-
 cially in scirrhus, before the tumour has made much  progress, or before
 there is any disease of the lymphatic  ganglions, or evidence of the can-
 cerous cachexy.
  " Ninth.   That many cases of tumours, especially tumours of the breast
 and testicle, supposed to be cancerous, are in reality not cancerous, but
 of a benign  character ;  and, consequently,  readily curable  by ablation,
 whether effected by the knife or by  escharotics.  It is to  this  circum-
 stance that we  must ascribe the astonishing success which is said to have
 attended the practice of Hill, of Scotland, Nooth, of England, and Fla-
 jani, of Italy.
  " Tenth.  That all operators insist  upon the most thorough excision
 possible; removing not  merely the diseased mass, but also a portion of
 the surrounding and healthy tissues, as well as all enlarged and indurat-
ed ganglions.
  " Eleventh. That  the practice has  alway prevailed, and still obtains,
to save, if possible, a sufficient amount of healthy integument to cover
the wound ;  and to unite, if possible, the wound bv the°first intention ;
on the  ground that these precautions will tend much to  retard, if not to
prevent, recurrence of the disease. 
AMERICAN APPENDIX.
849
   " Twelfth.  That much stress is laid by writers upon a properly regu-
lated diet, and attention to the bowels and secretions after operation, as
a means of retarding and preventing relapse.
   " Thirteenth. That there is no remedy, medicine, or method of treat-
ment, which has the power, so far as we are enabled to judge of its vir-
tues, of preventing the reproduction of the morbid action after operation,
no matter how early or how thoroughly it may be performed.
   " Fourteenth. That life has  occasionally  been  prolonged, and even
saved, by operation after relapse, as  in some of the remarkable  cases
mentioned in  a previous part of this report;  but that, as a general rule,
such a procedure is as incompetent to effect a permanent  cure as a first
extirpation.
   " The following points may be considered as of an unsettled charac-
ter ;  at all events, opinion respecting them is much divided, and farther
observation is necessary before they can be positively determined, either
affirmatively or negatively.
   " First. Excision is  of doubtful propriety in all cases  in which  the
disease is of hereditary origin, or where it occurs in several members of
the same family.
   " Second. It is doubtful whether an operation  should  be performed
when the patient is very young and the disease is of rapid growth. There
is reason to believe that surgical interference, in such a case, will only
expedite the fatal issue, which is generally inevitable.
   " Third.  It is problematical whether an operation should be performed
when the disease is attended by suppression of the menses, or by great
irregularity of this discharge.
   " Fourth. Not a few surgeons regard a resort to the knife as  of ques-
tionable efficacy where there is a quickened state of the pulse, occasioned
by the local irritation.
   " Fifth.  There appears  to be no general  agreement among surgeons
as to whether extirpation is proper when  there are two or more coexis-
tent and accessible cancerous tumors.
   " Sixth.  It is supposed, but the fact is not established,  that excision
of carcinomatous tumors only tends to hasten the patient's  death.
   " Seventh.  It is doubtful  whether, as  has been asserted by different
surgeons, the prospect of a permanent cure is greater, all other things being
equal, after an operation on an old cancer, than after an operation on a
cancer of recent standing.
   " Eighth. It has been stated by writers of great respectability, among
others by Dr. Macfarlane, of Glasgow, that in robust women of sanguine
temperament  the reappearance of cancerous disease, and its  subsequent
progress, are  more rapid after  operation than in  nervous or lymphatic
persons ; an assumption demanding verification.
   Ninth. It requires  to be proved whether excision ought  to  be per-
formed  in the ulcerated stage of malignant  disease, as a means  of pro-
longing life and of procuring comparative relief from suffering."
   The recent publication of M. Velpeau on the Maladies du Sein, &c,
1854, renders it incumbent on us to notice his views upon the propriety
of surgical interference  in carcinomatous affections of  this organ.  At
page 598, he remarks, that both observation and statistics have failed to
prove that  the extirpation of these tumors is always followed by a  re-
   Vol. III.                    107 
 850            NEW ELEMENTS OF OPERATIVE SURGERY.

 lapse, and that it is always  injurious, or  useless.   Again:  numerous
 facts in his own experience have convinced him  beyond a doubt, that
 radical cures have followed the operation for  cancers  " les mieux con-
 dition s.   At page 601, he adds, that extirpation should be the rule,
 whenever it is  in our power to  remove the whole of the morbid mass
 without subjecting the patient to too much risk of immediate  danger to
 life;  but that, under other circumstances, it should be renounced.  Every
 year  he refuses to  operate on  many patients.  Of fifty-two cases of en-
 cephaloid disease, he rejected fourteen as unfit for operation, and of 183
 cases of scirrhous, he refused it in fifty-four.   He is confident that he
 declines interference in at least fifty cases  annually.  Should the disease
 re-appear after extirpation, life may be prolonged, and in some instances
 a cure  effected, by repeating the operation ;—M. Roux having at length
 been  successful after the sixth  removal.    At page 685, he  furnishes
 other proof from his own experience.   Indeed, from what has  come un-
 der our own observation we know, that a  repetition of the operation, in
 cases of cancer, will in some  instances greatly prolong life, and Prot.
 Gross,  in his Report, p: 181, has  given the details of a  case,  in which,
 with other surgeons, we prolonged a patient's life for seven years, the case
 being, in the opinion of Prof. G., one  of the  most remarkable on record.
  In conclusion we would remark that M.  Velpeau has brought forward
sufficient evidence, we think,  to convince the  most sceptical, that but
little value can be attached to  the so-called  cancer-cell as a test for ma-
lignant disease.  Parotid tumors of an unquestionable malignant  character
have come under the observation of M. Sedillot, Professor Syme,  and
Dr. J.  Hughes  Bennett,  yet  no cancer-cell could be  detected.   For
further illustration of this point, we  would refer the reader to  the Clin-
ical and Histological Researches on Cancerous aud Cancroid  Growths,
by Dr.  Bennett, published in the Ed.  Month. Journal, for Jan. 1848, p.
478.
                           CATARACT.

  We copy from the Edinburgh Monthly Journal the following statisti-
cal results of the operation for cataract in the practice of Professor Ja-
ger, of Vienna.   They were originally published in the Behandlung des
gr. Staares, Vienna, 1845.
  Between the years 1827  and  1844, Prof.  J.  operated on 1011 cases
of cataract, of which 764  were lenticular,  207 capsulo-lenticular, and
40 capsular.  The methods of operating adopted were as follows :
       Extraction by the superior section in   -      728 Cases
           "      "     inferior    "                9   "
       Partial extraction            "       -    _   58   "
       Depression                  "       .      129   "
       Breaking down the lens       «       -    -   87   "

                                                1011

  Of the above number, 63 lost their sight; and the subjoined table gives
the relative order of the processes which gave the worst results:__ 
AMERICAN APPENDIX.
851
Of the  58 operated on by partial extraction    -    -   3
   "   737     "    " "         extraction    -    - 33
   "    87     "    " " breaking down the lens -       6
   "   129     "    " " depression            -    • 21
                                                              63

      The proportion of unsuccessful cases, therefore, being after extraction,
    4 1-2 per cent. ;  a depression, 16 per cent.; breaking down the  lens, 8
    per cent.
      These statistics certainly tend strongly to corroborate  the conclusion
    of Mr. Dixon, that depression is " an unscientific and  destructive oper-
    ation."  (Lond.  Lancet, June, 1853,  p.  578.)   Dr. Isaac Hays, in the
    last edition (1854) of Mr.  Lawrence's  Treatise on the Diseases of the
    Eye, p.  723, informs us that in this view of  the subject he fully coincides,
    and thinks  that  depression " will be ultimately abandoned, except in a
    very few  cases."   Mr.  Haynes  Walton, also, regards displacement as
    liable to grave objections, on account of the damage which must be neces-
    sarily done to the interior of a healthy eye.  When destruction  of the
    eye is threatened after this  operation, Mr.  Mackenzie  asserts  that  the
    surgedh should not hesitate to withdraw the displaced lens from the eye.
    This may be effected by introducing a bent needle through the sclerotica,
    and raising the cataract into its former situation.  Then it is to be press-
    ed forward  through the pupil, and retained in  contact with the  cornea
    till a section is made, a hook introduced, and the lens seized, after which
    it is to be extracted.
      Dr. Hays remarks (op. cit. p. 725) that  the   operation by  solution or
    absorption is that usually performed  by  his  colleagues and  himself at
    Wills Hospital, and that the results have been remarkably  satisfactory.
    He considers this method as applicable to a larger number of cases than
    has generally been supposed, and  states that it may be successfully re-
    sorted to even in hard  cataracts, by making several incisions in the  an-
    terior capsule, and freely lacerating this membrane  crosswise with  the
    point of the instrument.  After the partial  softening and  solution  of  the
•    lens which  follow,  it  may  be  completely  broken up at a subsequent
    period.
      In the text, M. Velpeau has expressed an unfavorable  opinion  of  the
    catoptric test, as a means of assisting our diagnosis in obscure cases of
    cataract, but Dr. Isaac Hays, in his recent edition (1854) of Mr. Law-
    rence's Treatise on the Eye, p. 675,  asserts that it affords  " the most
    unerring test."   He relates  two very interesting cases  illustrative of
    this point.   In one of them there was an opacity behind the pupil  which
    had a great resemblance to that of cataract.  The degree of vision en-
    joyed, too,  corresponded to  the degree of opacity, and the patient saw
    best by twilight.   On  applying the catoptric test, however,  the  three
    images were visible and of their natural appearance.  The disease was
    therefore pronounced amaurosis, and under a treatment directed  to the
    cure of this affection, the patient in a short time recovered.
     Mr. Haynes Walton, observes that he has not found the " candle test of
    Sanson"  so  generally  applicable, or so certain as he  had been  led to
   anticipate.    His  objection to it, is, that an eye, which  would appear 
 852             NEW ELEMENTS  OF OPERATIVE SURGERY.

 from the test to be glaucomatous, may at a later  period prove to have
 cataract.  He relates a case in corroboration of this remark.  Its prin-
 cipal value, he considers it to be  found in its application to the eye prior
 to the  amber change in the lens ; as, in that case, if amaurosis be pres-
 ent, the three images will be seen  clear and  not  blurred;  if incipient
 cataract, the  images within the eye  must be  affected  according to the
 degree and seat of the  existing opacity.  Although in the aged it may
 enable  us to compare the degree  of opacity  with the  imperfection  of
 vision,  in  consequence of the amber change in them, he asserts, the de-
 tection of incipient cataract is beyond its power. (Operative  Ophthalmic
 Surgery, Am. Ed.  p. 407.)
   We find in the Nashville Journal of Medicine and Surgery, for June
 1854, a paper by Professor Eve of that city, on " The state of the Pupil
 in Cataract.   Is it not contracted when it should be dilated, and the
 reason  why it is so ?"  His  observations have taught him that an errone-
 ous impression prevails in regard  to the true size  of the pupil in cases
 of cataract.  He quotes from the works of Messrs. Lawrence, J. Haynes
 Walton, T. Wharton  Jones, Alexander  Watson, M. Demarres, <fec. &c.
 to prove that the generally received opinion is, that the state of the pu-
 pil in this affection is almost always  natural.  Having studied  " with
 more than ordinary care, the peculiar state of the  iris" in cataract, he
 has arrived at the  conclusion that contraction of the  pupil  is " so uni-
 form and distinct  as to be almost  pathognomonic  of cataract."   This
 contraction he attributes to the reflection of light from the cataract upon
 the uvea or posterior surface of the iris.  "Its  convex  shape is well
 adapted to cast the rays from various angles of incident upon the deli-
 cate and hitherto well protected ciliary nerve.   The distance too is very
 short, and the impression made may be promptly and forcibly felt."  He
maintains there, that, photophobia is more frequently  experienced in
cataract than is admitted by authors.
                           COLLODION.

   In 1848, Mr. G. P. Maynard, a medical student, residing in Boston
first prepared this substance, an ethereal solution of gun cotton, and used
it as a substitute for the common adhesive plaster, and in many cases for
the suture.  It is now extensively employed not only in this country but
in Europe, and its use has been extended to many other purposes besides
those for which it was originally intended, as, for example, in various
cutaneous diseases, such as chronic erythema, eczematous and herpetic
affections, &c, &c.   It forms  an artificial cuticle, and is therefore indi-
cated in  abrasions of the  surface ; it contracts to a certain  extent, and
may be employed to produce slight compression, as in the milder forms
ol orchitis, varicocele, buboes, hemorrhoidal tumors, &c  &c   Dr  Har
nss, of Augusta, Ga., has furnished us in the  Southern Medical and Sur-
gical  Journal, for December, 1853, with  the most comprehensive sum-
mary which  we have yet seen on the use of collodion in the treatment of
various affections.
   In the London Lancet,March 17th, 1849, M. Schonbein, the inventor 
AMERICAN APPENDIX.
853
of the gun cotton, states that he had long since recommended for surgi-
cal use a liquid which he called " Liquor  constringens," or ether glue,
and that it had been employed in Switzerland, three  years previous to
any notice of it in America.  To maintain  the edges of an incised wound
in apposition, a piece of cambric or linen rag should be dipped in  the
solution, and placed along the line of incision, the margins having been
previously dried, a condition essential  to  the adhesion of the solution.
The film left by the evaporation of the ether, is liable to crack from want
of elasticity, and to peel off; this may be prevented by combining a cer-
tain  proportion of  oil with the ethereal solution of gun-cotton.   Some-
times the solution is colored of a flesh-color, and may thus avoid notice.
                         DISLOCATIONS.

   It is not our  purpose to enter into a lengthy  discussion of the treat-
ment of dislocations.  We propose, rather, to notice briefly the improve
ments which  have lately been made in this department of surgery.  Sir
Astley Cooper  insisted that the pulleys were  indispensable in the re-
duction of dislocations  of the femur, yet the late Mr. Morgan, of Guy's
Hospital, London, for  more  than  twenty years before  his death  was
accustomed to effect their reduction  without resorting to these " indis-
pensable " agents, and he maintained that they were quite unnecessary.
When  called to a recent case of dislocation of the femur, he placed his
heel between the thighs, and made extension downwards.  In many cases,
he found  advantage from  flexing  the affected limb, with the knee bent
on the body, and  at the  same time  making  forcible  flexible rotation.
Mr. Birkett, one of the surgeons of the  same institution, in  a communi-
cation  to  the London  Medical Times and  Gazette, for March, 1854,
states  that he has succeeded  by Mr. Morgan's method,  in reducing al-
most all forms  of dislocation, and he asserts  that the special rules laid
down in books  as to the direction of traction  to be observed in each,
have not been found of so much practical importance as they were  sup-
posed to be.  Dr. Physick, as well as Dr. Nathan Smith, often succeeded
in reducing dislocations, even of the femur, without the  aid of  pulleys ;
and a similar success has been recorded even by Paulus iEgineta and
Hippocrates.  Dr. John Watson has collected  sufficient evidence upon
this subject to show that this practice is  by no means of  modern origin
(N.  Y. Med. Times, June, 1853,) though there can be no doubt  that
the labors of Dr.  William W. Reid, of Rochester, N.  Y., have done
more than those of  any other surgeon, especially  in this country, to re-
commend  and establish the reduction of dislocations without the aid of
pulleys.   In  a  very interesting paper by this gentleman, published in
The Transactions of the Medical Society of the State of  New-York, for
1852, he states that for many years his attention has been  directed to this
scbject, and  after numerous  experiments, he  has  satisfied himself  that
" the chief, if not the sole difficulties to be overcome in  dislocation  of
the femur, and  probably in all other  dislocations, consist in the  exten-
sion of certain muscles involved in the dislocation, and in  their incapabil-
ity of further extension without danger or rupture; and that, in the case 
854
NEW ELEMENTS OF OPERATIVE SURGERY.
 of dislocation of the femur, the difficulty lay  in the extension of the
 aforementioned adductors and rotators, and that all traction, on the dis-
 located bone, only increased this tension and could  do nothing towards
 bringing it into place,  except at the  hazard  of almost  certain rupture
 of some of  these muscles, or of fracture of the neck."  His method of
 operating, is as follows  :
  "Place the patient on  his back, on a low, firm table;  the floor or ground
 is better ; let the operator stand  or kneel on the injured side, and  seize
 the ankle with  one hand the knee with the other;  flex the leg on the
 thigh ; next, strongly adduct it, carrying it over the  sound one, and  at
 the same time upward over, the pelvis, by a kind of semi-circular sweep,
 as high as  the umbilicus; then abduct the knee gently;  turn  the  toes
 outwards ;  the heel inward and  the foot across the opposite and sound
 limb, making  gentle oscillations of the thigh, when the head of the  bone
 will slip into its socket with a slight jerk, an audible snap, and the whole
 limb  will slide easily down into its natural position  beside the other.
 In a recent case, the whole operation can be  accomplished in  less time,
 than it can be described."
  The advantages claimed for this proceeding are, 1.  its simplicity ; 2.
having the consent  of the will, the movements being natural; 3, it pro-
duces little or no pain ;  4, the flexors and extensors alternately contract
and relax in unison with each other ;  5, no tonic or involuntary spasms
to contend with ; and 6th  it is the best method in cases of long standing,
 and is free from danger under all circumstances.
  Dr. Reid  concludes his article with  a report of several cases  in which
reduction had been  accomplished according  to his method, and it was
stated by one of the surgeons of the New York Hospital, this day, (May
23, 1854) that nine cases of  disolocation of the femur  had been sucess-
fully  reduced on this plan, in that institution.  At  the same  time we
saw another, a disolocation  into the foramen ovale, reduced, but not
until  many  and  fruitless  efforts had  been made.   This, however, was
owing to inexperience in the application of the  method in that  variety
of dislocation.
  Dr Fahnestock of Pittsburg, makes  use of the power of  twisted rope,
instead of the pullics, in the treatment of dislocations.   Dr. Gilbert  pub-
lished an account of this  method in the American Journal of the Med-
 ical  Sciences, for April, 1845.  It is employed in the following manner.
  " Place tho patient and adjust the extending and counter-extending
bands, as for the pulleys;  then procure an ordinary bed-cord , or wash
line, tie the ends together and again double it up on itself ;  then pass 
AMERICAN APPENDIX.
855
 it through the extending tapes or towel, doubling the whole once more,
 and fasten the distal end, consisting of four loops of ropes, to a window-
 sill or staple, so that the ropes are drawn moderately tight; finally, pasa
 a stick throughout the centre of the doubled rope, dividing the strands
 equally by it.
   Then revolving the stick as an axis or double lever, the power is pro-
 duced exactly as it should be in such cases, viz. slowly, steadily, and con-
 tinuously ; which, with the aid furnished by the surgeon to the immedi-
 ate  seat  of lesion, and to the system in general, cannot  fail to conduce
 to a happy issue."
   We need  hardly  observe, that in the reduction  of dislocations, the
 great value of anaesthetic  agents is particularly shown.
   Congenital dislocations  of  the head of the femur  are  sometimes,
 though rarely, observed.   Cases of the kind have been recorded by Pal-
 leta, Dupuytren, Breschet,  Sedillot, Pravaz, Robert, and Dr. Carnochan,
 of this city.   The  latter surgeon  has recently produced one of the most
 valuable works on this subject which have yet appeared.   Dr. Carnochan
 is of the opinion that  the dislocation in question, " is the result of spasmo-
 dic muscular  retraction, not dependent, however, upon mere  absence of
 the central nervous substance,  but upon an irritation conveyed to, or ori-
 ginally existing in, the ganglionic centre of the medulla spinalis.   This
irritation, or altered  action, which occasionally may result in structural
lesion, is  thence  transmitted by the  reflex-motor power  of the excito-
motor  apparatus of  the spinal system upon the  muscles, which conse-
quently become affected, and by their continued retraction, disarticulate
 the head of the femur."—p. 26.
a. Anterior superior spinous process of the ilium
b. Trochanter major.
c. Os coccygis, tilted upwards.
d. Upper margin of the patella.
  The appearances presented in this form of dislocation are represented
in the above figures.   The treatment of these cases has hitherto proved 
856
NEW ELEMENTS OF  OPERATIVE SURGERY.
so very unsatisfactory that many surgeons of repute have doubted the
efficacy of any means as yet proposed.   Dr. Carnochan has reproduced
the methods employed by M. Pravaz, and described by the latter, in his
Traite des  Luxations Congenitales du  Femur, 1847, but has reported
no case treated  by himself.  For further details,  we must refer to the
works of either of the last named surgeons.
                EMPHYSEMA OF THE EYELIDS.

   In the appendix to the last edition, M. Velpeau refers to a case report-
 ed in the  Gaz. des Hop., 1839, p. 174, in which a man blowing  his nose
 too violently after an operation for fistula lachrymalis, that Blandin had
 performed upon him, was suddenly  seized with a strongly-marked em-
 physema of the eyelids.  In an article by  M. Meniere, published in the
 Arch. Gen. for March, 1829, p. 341, and entitled, " Sur quelques cas rares
 d'emphyseme dependant de causes differentes," are reported two cases of
 emphysema of the eyelids, one of which resulted from a blow inflicted at
 the inner angle of the eye, the other  from a violent expiratory effort  of
 a patient dying in convulsions.  On  examining the parts after  death, a
 fracture of the orbitar  arch  was  found, together  with a  rupture of the
anterior lobe of the brain.  Dr. Hanford N.  Bennet, of Bridgeport, Conn.,
has informed the writer of a case of traumatic emphysema of the lids,
which occurred in  his  practice.   The  treatment  of such cases  must  of
course depend upon the nature of the cause.
EMPYEMA.
  The unpleasant consequences which frequently followed the operation
of paracentesis thoracis  as  formerly  performed, were sufficient to deter
many from resorting to  a  proceeding which may,  if properly executed
be  productive of the most satisfactory results.   Drs.  Hamilton Roe'
Beyran and Bowditch, have most contributed to establish the propriety of
this operation, and the fact that it is not more dangerous than many others
performed upon the  human body.   The  papers of Dr. Roe, in the Tran-
sactions of the Royal Medical and Chirurgical Society of London, vol.
xxvii., and of Dr. Bowditch, in the American Journal of Medical Sciences
April, 1852, are doubtless familiar to many  of our readers.  The latter
gentleman has quite recently published  more extended observations on
the  subject, in the American  Medical Monthly, for January and  Feb-
ruary, 1854.  Dr. B. adopts  Dr.  Wyman's method, viz., the exploring
trocar and suction pump.  The trocar being small is easily introduced
makes but a slight wound, and there is no liability  of a fistulous opening
remaining.   Since April, 1850, he has operated fifty times, (Bost. Med
and Surg. Journal,  Feb.  22, 1854.)  He always  passes the trocar
directly in, without using the  scalpel previously, or needing any valvular
fold of the skin, as no air can get into the pleura by this method.  When-
ever he has obtained fluid,  viz., forty-seven  times  out of 50, relief has 
AMERICAN APPENDIX.
857
always been obtained, and he has never seen any evil result.   The extra-
ordinary number of  cases thus  treated in  less than four years, would
lead us to suspect that he resorts to the operation  early in  the disease.
In a paper read  before  the  Boston Society for Medical Improvement,
February 13,  1854,  he states, that his  rule is, never to  let fluid remain
for a long time  or in  large quantities  in the chest.   " I consider  para-
centesis  as the first  remedy to be used when called to a case of pleuritic
effusion  of any  duration, in  which the amount of fluid is  large, or in
which any serious symptom  exists."  He remarks  that he should feel
guilty of a neglect of duty to his patient, if he did not urge the operation,
in any case, after  the  existence of effusion  has been manifested a few
weeks,  and when remedies  do  not seem to effect its  cure.  He feels
bound to resort  to it in any case of large effusion, however short a time
it may have existed; in a word, he regards " thoracentesis" as he regards
other remedial agents, to be used as freely as he uses them, viz., whenever
he thinks it necessary.  This method by the trocar and canula, as per-
formed  by Trousseau  and Hughes, and especially as modified and im-
proved by Dr.  Wyman, he considers as one of the simplest and safest of
all  operations.  The annexed table of cases in which he has operated
will, therefore, be presented with interest.   We take it from the Medical
Monthly, for February, 1854.
  As will have  been noticed in the text, M. Velpeau is disposed to re-
gard the operation of paracentesis in cases of empyema, as a  very trifling
affair; but we think that there are many who will not coincide in his
opinion.   In pneumothorax he disapproves of the operation, on the ground
of its inutility.  Dr. Hamilton Roe, a  good authority in these matters,
has published  in the London Lancet,  for  January, 1852,  Am. ed., a
paper on the  utility and necessity of performing  paracentesis thoracis
in certain cases of this affection.   He considers the operation necessary,
when air is accumulated in such a quantity as  to cause a degree of diffi-
culty of breathing which is  dangerous to life.   In such cases he would
operate immediately, for  the compressed lung  will soon become carni-
fied, and the  other will be so congested, that the removal of the air at a
later period, will be useless, the permeability of the lung being destroyed,
and the brain  so injured by the circulation of carbonized blood, that life
cannot be preserved.   To guard against one of the principal objections
to this operation, viz., the reaccumulation of air  in the cavity, he advises
that the  wound  be kept open; when, if healthy, the lung will expand,
and by coming into contact with the costal pleura, contract adhesions,
and  obliterate the pleural cavity.  He  then relates some cases, show-
ing that this  result may take place.   Dr. Copland, in his Dictionary
of Practical Medicine, &c, remarks  that  a gentleman who  possessed
such a good condition of body as was incompatible  with the  existence
of any grave alteration of structure, died of pneumothorax, because para-
centesis  was  not  performed.  We have good grounds, therefore, for
asserting that, in certain cases, as mentioned by Dr. Roe, this operation
is not only proper, but necessary.
  vol. in.                     108 
Tabular Statement of Operations for Paracentesis Thoracis, performed between  April 1850, and Oct. 1853.
GO
oo
No.	Aire k. date	Piofession.	Previous diseases.	How long- sivk be tore first opera-tion.	No. of operations and dates.	Character of the fluid.	Amount of the fluid.	Immediate effect* of the ope-ration.	Bow soon the lungs ex-1 landed and heart fell nto nor3ial position.	Final Result.
1. 2. 3.	28. April 17, 1850.	House painter.	none.	5 weeks.	1st, April. 17. 2d,	nothing. pus.	S ix.	relieved of oppression at chest.	not immediately & doubtful how soon, ess than 4 weeks.	perfect health after j or 6 months.
	56. Oct. 1, 1850.	Seaman.	dyspnoea for 6 or 7 years— probably heart disease.	at least seve-ral months.	1st, Oct. 1. 2d, " 12.	serum. serum coagu-lable.	§ xxxvi. S xxxij.	great relief; orthopncea ajone. some 'drawing' around chest.	on 5th diiy, or per-iiaps sooner; fric-tion sound next day.	death many weeks afterwards with cardiac disease.
	28 Julv, 1850.	Machinist.	rheumatism; soreness for 3 months in left breast.	3 months.	1st, July 10. 2d, " 12. 3d, «« 14. 4th, " 19. 5th, Aug. 11. Two natural	bloody. serum. more purulent	few drops Si-§ xxvi. a little. Oj.	'easier, pulse better, relief to distension ^ and to pulsation of the heart to the right of the sternum. marked relief to dysp-	heart fell immedi-ately toward left two inches.	gradually failed, and died about the middle of August.
4.					openings sub-sequently took place.			noea.		
	48 June 4, 1850.	Carpenter.	had raised blood many times.	10 weeks.	1st, June 9. 2d, " 11. 3d, " 11. 5th, Nov. 19. 6th, " 21.	purulent. nothing. purulent. pure pus.	few drops S «• Six.	C great relief. \ stronger. relief.	20 days after ope-ration " respirato-ry murmur bet-ter," less dull per-cussion. C rubbing sound } at the point of ( puncture.	gradually got well after many months; chest contracting and lower lobe re-maining condensed
5.	6 July 14, 1851.	Girl	unknown.	unknown.	1st, July 14. 2d do. 3d do.	serum. do. do.	few drops merely could be drawn.	no effect, neither relief nor trouble.		nearly in articulo mortis, and died soon.
 
6.	18 or 20 years.	Young man	unknown.	unknown.	1st, 2d,		nothing.	do.		unknown.
7.	29. Aug. '21, 1851.	Spinster.	cough and diarrhoea for many months.	2 weeks.	1st, Aug. 23.	serum coagu-lable.	S xli.	unpleasant feeling a-bout chest, but soon great relief. Heart fell back 1} inches.	next day murmur heard everywhere; minute crepitus.	well of effusion in a week—died a year after, of phthisis.
8. 9. 10.	31. Sept. 3, 1851.	Wife.	pleurisy pain years ago, but well after.	10 days.	1st, Sept. 3.	serum coagu-lating on standing.	S xiii.	great relief—no orthop-noea afterwards.	next day.	well by 12th day after the operation. Patient attended to household duties. A few physical signs remained.
	20 Oct. 17, 1851.	Clerk.	cough, winter previous.	48 days.	1st, Nov. 1. 2d, 3d, Dec. 13. 4th, Jan. 14. 5th, Feb. 9.	yellow, amber-like. a little opaque more purulent	§ xxv iii. § xviii. S xxi. S xxi.	great relief—no severe dyspnoea after 1st. Pa-tient desired all the rest when he found dyspnoea coming on. Cough bad after them all, stricture after last.	lung expanded somewhat at apex; never fairly dis-tended.	after many months died of phthisis.
	oO Feb. 17, 1852.	Rigger.	cough for a year.	71 days.	1st, Feb. 27. 2d, " 3d, 4th,	purulent. << IS	a little. S xv-S ii>-nothing.	C great relief to dis-\ tress of patient. ( patient almost in ar-( ticulo mortis at time.	not at all.	death on 4 th, after last operation.
11.	59 Dec. 29, 1852.	Soldier.	none known, character dis-sipated.	5 weeks.	1st, Dec. 29.	yellow serum.	§ xxiii.	relief to fulness—able to lie on either side.	lung came up slow-ly—friction noticed 30th, perhaps be-fore.	death two months after with cephalic symptoms.
12.	21 Feb. 27, 1852.	Wife.	cough during autumn.	6 weeks.	1st, Feb. 27. 2d, natural opening sub-sequently took place.	thick pus.	S xli.	great relief to orthop-ncea and general un-easy state.	lung had expand-ed somewhat on 5th day; on 11th much more.	perfect health after many months.
 
Tabular Statement of  Operations for Paracentesis  Thoracis.—Continued.
00
Ci
o
No. 13. 14. 15. 16. 17. 18.	Age k. date	Profession.	Previous diseases.	How lon? sick be-fore first opera-tion.	No. of operations and dates.	Character of the fluid.	Amount of the fluid.	Immediate effects of the ope-ration.	low soon the lunirs ex-panded and heart fell nto norma! position. ung did not come up readily before death.	Final result.
	40 Dec. 30, 1850.	Laborer.	slight dry cough a week before fall, which caused his pleurisy.	5£ months.	1st, Dec. 30. 2d, Jan. 10.	pus. pus.	S lxiv. Sclxx(!)	great relief to dyspnoea and moaning, cough af-ter puncture.		death from opiate.
	24. March, 1853.	Clerk.	cough years ago, but well before acute attack.	12 days.	lBt, March 20	serum coagu-lating.	§ xlviii.	relief—dates recovery from operation.	next day lung ex-panded at upper part; lower never did.	recovered, with condensed lower lobe after months.
	45. June 10, 1853.	Wife.	cough for many months.	6 weeks.	1st, June 10.	do.	§ lxxxiii and 3^i-	entire relief from threat-ened suffocation — bad cough—pulse fell—co-pious frothy expectora-tion.	immediate expan-sion of major part of lung.	10 days no differ-ence on percussion of both lungs; well of pleurisy.
	Julv 11, 1853.	Laborer.		4£ months.	1st, July 11. 2d, August 5, patient asked for operation.	colored serum, do.	§ xxiiiss. I xiii.	respiration less labored —comfortable day—lit-tle relie .	no physical signs given.	death some days after last opera-tion.
	6 Oct. 20. 1853.	Boy.	*	many months.	1st, July 18.	pus.	S xiii.	slightly easier.	never.	death months after.
	19 July 18,	Clerk.	none.	7 months.	1st, July 19.	serum coagu-lating.	§ Ixxx.	no immediate trouble, and all the functions of the body immediately began to go on well.	murmurs heard tc base of lung next day.	perfectly well in about a month or six weeks.
*N. B.—The patient had been operated on by Dr. Wyman many times. 
Sx. §iv.	stricture and faintness relieved on lying down; can lie on left side; re-lief to cough.	no marked change except tubular res-piration more man-ifest.	Ideath in two weeks,, with tuberculous lungs. 1
§ xviii.	nausea, vomiting, little cough—felt as if " had lost part of her side."	heart fell to place; next day crackling throughout expan-ded lung.	in 10 days no ef-fusion remaining— equal resonance in back. Dyspnoea (?) from tubercles re-maining.
drops, §liv.	a little faint—great re-lief to pressure and dyspnoea.	crackling immedi-ately.	Oct. 6, percussion equal both backs and respiration pure.
§ lxxvi.	felt a little weak. •	heart fell towards place 1£ inches; murmur heard in-distinctly.	gradual improve-ment from time of operation. Under treatment.
S l^iv.	cough considerable— one or two bloody sputa —much relieved of weight—able to lie on either side.	lung did not easily come up, air took place of fluid.	lung very slowly expanding—s till much air, no re-turn of fluid in pleura; under treatment.
§ xxiv.	relieved from pressure.	murmur along ver-tebrae, and crack-ling lower down.	improving in strength, &c. un-der treatment.
nothing.	no effect, neither un-pleasant or otherwise.		
 
862
NEW ELEMENTS OF  OPERATIVE SURGERY.
   The Appendix, by  M. Yelpeau, in the last edition, contained the fol-
lowing :
   " M. Heyfelder, (Archiv. Gen. de Med., Mai, 1839, p. 59,) following
my method of operating for empyema : first, in a child aged seven years,
at the end of two and  a half months of the disease ;  second, in an infant
aged six years, at the end of three months and a half; third, on a soldier
aged twenly-one years, at the end of some weeks ; fourth, on a boy aged
six years;  fifth, on a child aged seven years, obtained  success  in each,
except that the wound in his third patient  remained fistulous.   A like
result was obtained by M. Brugnon (Ibid., p. 80)  in  May, 1837.   F.
"Wetzel, (Heide/b., ann. 1838, t. iv., cap. 4; Arch Gen. de Med., Juin,
1839, p. 229,) aged nineteen years, operated upon for empyema the 21st
of June, 1834, and several times afterwards,  was still  living in 1838,
with a fistula in the thorax."
ENTEROTOMY.
  ^ A correspondent of the Boston  Medical and  Surgical Journal has
 given an  account of an operation which it is said M. Maisonneuve per-
 formed twice in January, 1855, at the Hospital Cochin.  This operation
 was for the purpose of uniting the small and large intestines, in case of
 obstruction, so that a new route might be  established for the passage of
 the  fascal _ contents.  He  considers it  applicable to those  patients who
 have submitted to the operation for strangulated hernia, and where spha-
 celus has  attacked  the  portion  of intestine contained  in the sac to
 such an extent, that it is not prudent to return it till the gangrenous por-
 tions have  sloughed away.   Also, in those cases where the5 hernia has
 been reduced by the taxis, but the bowels refuse to  act;  and, finally, in
 any  case  where  there is intestinal  obstruction.  Both of  the  patients
 who submitted to M. Maisonneuve's operation died, although one was in
 a moribund state when subjected to the knife, and the other in a very de-
 bilitated state.   The  first, a man aet. 50, entered the hospital, suffering
 from inguinal hernia, which, however, was reduced by the taxis   The
 bowels refusing to act for several days, notwithstanding the use of pur-
 gatives, Ac, the patient was placed upon the back, being a little inclined
 to the  left side, and  an incision  was made in the  abdominal  pariete,
 from five to six inches in length, on  a line with the body, just above the
 crest of the ileum.  The coecum was sought as a fixed rallying point of
 departure   Then a portion of the intestine above  the strict™, which
 can be easily recognized as being distended with fa3cal matter, was at-
 tained; also a fold below.   These were  then were brought together and
placed parallel  to each other   The superior portion w°as incised, w?th
a pair of scissors, the length of six inches, and the distended parts above
carefully emptied of  their contents.   The lower fold was  incised in like
manner but the bowel contained nothing to be dia»onred    These tubM
 ™ side by side-their internal walls were united^yTs'impl^ suture-
Wn '  f .SUfCeS eing !? C°™Ct' f °methinSlike th° ^am of a garment
before it has been pressed.   Then the internal walls of each  tube were
 brought together by turning the incised edges inward-30 that the seToSs 
AMERICAN APPENDIX.
863
surfaces, as before, should be in juxtaposition—and  united by a suture,
armed with two needles.  Thus the free margins and the serous surfaces
were in proximity, so that agglutination  might take place with facility.
This being done, the intestines were returned, and the external incision
dressed in the  ordinary manner.  The patient lived  seven days.  The
fifth day he had  free evacuations, whether from the new or   old  route
was unknown ; he finally sank from peritonitis.
   The second patient was a man who entered the Hospital with strangu-
lated hernia, of eight days' duration.   The abdomen around the hernial
tumor presented  a yellowish tint, showing that evidently  there was
already sphacelus in the constricted intestine.   The operation for hernia
was made, and the bowel was found too gangrenous to be returned into
the abdomen, but was opened to  give exit to a large  amount  of fsecal
matter, liquid,  <fcc, and left in the incision.  Two days after, the patient
having had no discharge, and being almost in a state of collapse, the
same operation as mentioned above was performed, but without any par-
ticular hope of success.
   It is to be regretted that  no accurate notice of the appearance of the
parts  contained  in the  hernial tumor,  accompanies  the  report of the
operation in the  first case;  for, the reduction having failed to afford re-
lief, most surgeons, we  think, would have concluded that the hernia had
been returned in mass, and would have directed their operative proceed-
ings to an exploration of the parts in the immediate vicinity of the tumor.
It is  stated  that M. Maisonneuve has  performed the operation above
mentioned many times upon dogs, by strangulating a portion of the intestine
and uniting a portion above and below the point of  strangulation, with
complete success.  But, it is almost needless to observe, peritonitis is
much less frequent in  dogs after mutilation  of the peritoneum, than  in
man.
   A remarkable case of enterotomy was performed by Dr. Samuel White,
of  Hudson,  N.  Y.,  in August, 1806.  The patient  had swallowed a
spoon, which became lodged in one of the convolutions of the  ileum near
the line dividing the right iliac  and hypogastric regions.  An incision,
three inches long, was made through the abdominal parietes, and parallel
with the epigastric artery, extending upwards to the crest of the ileum,
and the peritoneum was opened with a lancet.  The  fold of intestine,
containing the  spoon, now protruded,  and was pierced with  the lancet
over the end of the handle,  and the spoon extracted  by forceps.  The
edges of the wound  in the intestine were then secured by the Glover's
suture, and the external wound closed with  adhesive plaster and lint.
The patient soon recovered, (N. Y. Aled. Repos. vol. x., p. 367, 1807.)
   Mr. Benjamin  Phillips has  most thoroughly examined the  results of
enterotomy practised for the relief of intestinal obstruction from volvulus,
the pressure of tumors, &c, &c.   His memoir  was published in the Med.
Chir.  Transactions, vol. xxxi., Lond. 1848.   After alluding to the diffi-
culty of arriving  at an accurate  diagnosis  in  these cases, Mr. Phillips
remarks:
   "Interference by surgical opera'tion is justifiable when three  or four
days have passed without any relief from ordinary means (provided the
constipation be complete, and  vomiting of fecal matter  continue) be-
cause, it affords a greater chance for the preservation  of life than ordi-
nary  means. 
864
NEW ELEMENTS OP  OPERATIVE SURGERY.
    "If the indications as to the seat of the obstruction be  sufficient to
 satisfy the surgeon, it is at or near that point that the  incision should
 be made;  but if there  be much  doubt, it is most prudent  to make the
 incision on the median line.
    " That if it be found impracticable to remove the cause of the obstruc-
 tion, or imprudent to make any extended search fer it, relief may be ob-
 tained by  forming an artificial anus as near as may be prudent to the
 seat  of  obstruction ; and, if it  be,  as  it frequently is,  near the ter-
 mination of the ileum, an incision on the median line admits of its accom-
 plishment  as near as  may be to the termination of that intestine."
   Dr. Manlove,  of Tennessee, has reported in  the  Bost. Med. Surg.
 Journal, vol. xxxii. p. 492, a remarkable case of enterotomy which was
 successfully  performed for volvulus.   In his  report  he  refers, also, to
 another successful case in the hands of Dr. Wilson of the same  county.
   The instances in which enterotomy, or gastrotomy has been performed
 for the purpose of extracting foreign bodies from the stomach are so rare,
 that we do not hesitate  to copy in detail  the following report  from the
 Philadelphia Medical Examiner, April, 1855.

 Case  op Gastrotomy for the Removal of  a Leaden Bar.—Recoy-
    ery.   Reported by T. B. Neal, M. D., Columbus City, Iowa.

 Editor Medical Examiner:
   Dear  Sir :—I  transmit, for insertion in  your valuable journal, the fol-
 lowing remarkable and perhaps unique case.
   The subject of  this notice, L. Bates, aet.  27, resides at Wapello, twelve
 miles from  this city.   During the three days preceding Christmas last,
 he had been drinking freely of common whiskey ; and on that day, while
 intoxicated, attempted, on  a wager, to swallow a bar of lead. The  bar
 was 10 inches long, \ by | inches thick, and weighed one pound.
 _  Thrusting it far down the oesophagus, it slipped from his grasp, and
 immediately entered his stomach.   Dr. Bell was sent for at once, but as
 Bates had formerly been a juggler, the  Doctor, thinking that he was at
 some of his tricks, refused to go.   Bates, not much concerned at  the non-
 attendance  of the physician, worked for three days after the accident in
 a pork-house, with but little inconvenience.  During  the  night of the
 third day, however, he was seized with great pain in the stomach, accom-
 panied with shooting pains along the spine, extending  from the  lumbar
 region to the  sacrum, and thence to the hips.  The next day he walked
 to Columbus^a distance  of six miles, and sent for Dr. Robertson, the
oldest physician in this county, to attend upon  him.   Dr.  R. requested
me to see the case with him.   We found him,  on the  fourth day, com-
para ively easy   His  tongue was  white, breath very foul, and bowels
constipated.  Upon careful examination, the oesophagus was found per-
fectly free and unobstructed.  We administered to him morphia in small
doses, and attempted to act upon his bowels and neutralize the poisonous
enects  of the  lead by large doses of. sulphate of magnesia.   Under this
treatment, although the bowels were but slightly disturbed, he was ren-
dered astonishingly comfortable, and could  walk about a little.  On the
ord ot  January, the 10th day after his accident, the severe gastric pain 
AMERICAN APPENDIX.
865
 again returned, accompanied with vomiting, and other symptoms of gas-
 tritis.
   The operation of gastrotomy was now resolved  upon.  Dr.  Bell of
 Wapello performed the operation, by making an incision through the walls
 of the abdomen, from the umbilicus to the false ribs, four inches in length
 and two inches to the left of the median line.  The peritoneum  being
 divided, Dr. Bell introduced his hand, and pushing  back  the protruding
 intestines, found that the bar of lead was nearly perpendicular, the upper
 end inclining a little to the left.   The bar was pushed up, until the lower
 end came opposite  the  abdominal opening.  It was then seized, and an
 incision made in the walls of the stomach, just large enough to admit of
 its extraction by means of  forceps.  The  contraction  of the  muscular
 coat of the  stomach caused the  incision in the organ to  close  perfectly
 and without trouble.  The external wound was stitched, and a compress
 applied.
   The operation was performed  between three and four  o'clock, P. M.;
 the  day was cloudy, and towards sunset  grew quite cold.  The  patient
 was entirely under the influence  of chloroform  until about two minutes
 before the  last  stitch  was taken, when he revived somewhat, and ex-
 pressed  himself  as  feeling  better than he had done before.  When the
 chloroform was first administered to him, he vomited freely, hence,  when
 the  opening was  made into the stomach nothing escaped  therefrom, that
 viscus containing nothing but the leaden bar.
   For the ensuing three days the system of the  patient was kept under
 the  influence of opium, and nothing but  mucilaginous drinks, in  small
 quantities, allowed  as diet.  He  recovered as well  as a patient  does of
 uncomplicated gastritis.
   I  give you below the condensed notes  of  the progress of  the  case,
 taken by Drs. Bell, Robertson, and myself.
   January 4th, 10  A. M.—Patient tolerably quiet; pulse soft, and  mod-
 erately full; some fever and thirst; vomited once ;  bowels moved freely
 during the night, though he has been taking small doses of morphia every
 two  hours ;  complains of pain in the stomach and bowels  ; continued tho
 morphia, and ordered two tablespoonfuls of toast and water every two
 hours.
   3  P. M.—Patient stilll quiet;  pulse 85, and rather hard.  Took gx.
 blood from the arm.  Continued  morphia and toast-water.
   January 5th, 10  A. M.—Rested well last night;  bowels undisturbed
 for eight hours, then at 4 A.  M., watery dejections ; complains of nausea;
 pulse 83, and soft;  tongue white ; no  soreness  in  the gastric region;
 some cough ;  ordered the  following pill every  two hours and a half:—
                 R. Hydrarg. Chlorid. mit.  gr. ss.
                     Pulv. Ipecacuanha?       gr. j.
                     Morphia? Sulphat.        gr. \.
                  M. ft. pil. i.
   5. P.  M.—Complains of heart-burn, nausea, thirst, and frequent alvine
evacuations ; pulse  73, strong and full; .craves acid  drinks.  Prescribed
a weak solution of  citric acid ; it did not appear to agree with the stom-
ach ; at  9  o'clock slight vomiting: therefore directed morphia,  gr. ss.,
ipecac, pulv. gr. ii.   llj o'clock,  administered morphia, gr. ss.   In  half
an hour patient fell into an easy sleep, his pulse growing softer.   Direct-
   Vol.  III.                   109 
866           NEW ELEMENTS OP OPERATIVE SURGERY.
ed gum-water and ice-water, a table-spoonful alternately every half hour,
and the morphia every two and a half hours.
  January 14th.—Met patient standing in the door; appetite good, pulse
70, and soft; wound looks  well; dressed it, and ordered one blue pill,
to be followed by enema if it failed to operate.
  On the 16th the wound was nearly healed, and he had walked half
a mile  to  see a neighbor.  At  the  time  of writing  this hasty  epistle,
(Feb. 19th,) he has been out of the settlement some two weeks, and I
learn has been at work.   What his exact condition  is at present, I do
not know, not having seen him since he  began  to  go abroad.
                             Very respectfully, &c,
                                                     T. B. Neal.

  In his edition of Chelius' Surgery, Mr. South has made the following
note:  " Barnes quotes from Becker the case of  a young peasant, who, on
29th May, 1635, whilst endeavouring to produce vomiting with the handle
of a knife, let it slip from his  fingers and pass  into  the  stomach.  He
was much frightened, but able to go about his usual occupation.   I was,
however, determined to remove the knife by operation, which was done
on the 9th of July following, by a surgeon and lithotomist, named Shoval.
'A straight  incision was made in the  left hypochondrium, two  fingers'
breadth under the false ribs ; first through the skin and  cellular mem-
brane,  then through the muscles and peritoneum.  The  stomach subsided
and slipped  from the fingers, which prevented it from being immediately
seised: but  it was at length caught  hold of with  a curved needle, and
■drawn  out of the wound.   A small incision was then made into  it upon
the knife, which was then easily extracted.   The stomach  immediately
collapsed.   After the external wound had been properly cleansed, it was
united  with five sutures, and tepid balsam poured into the  interstices.
Tents impregnated with the same balsam, and a cataplasm of bolar earth,
the white of egg, and  alum, were then applied.'  (P. 324.)  Two su-
tures were removed next day, on  the following  day  two  more, but  the
fifth is  not noticed.  On the the fourteenth day after the operation  the
wound  had healed.  Dr. Oliver saw this knife at Konigsberg in 1685,
and says it was six inches and a half long.   The patient completely re-
covered."
  Some twelve years since, we opened the abdominal walls with the view
of extracting a foetus which (extra uterine) had remained in the cavity
for eighteen months.  The intestines had formed extensive  adhesions to
the sac, and there was a  perforation of  the  descending  colon, through
which  one of the  lower  extremities had descended so  as  to protrude
below the anus.  So great was the disorganization of the  intestines, that
the patient survived the operation only 24 hours.   Intestinal obstruction
had been complete for more than a fortnight before the woman's death.
                           EPIPHORA.

  In the 34th volume of the Medico- Chirurgical Transactions, p. 337,
Mr. William Bowman, the accomplished physiologist  and oculist, of 
AMERICAN APPENDIX.
867
London, has described a form of this affection dependent upon a displace-
ment of the  puncta, generally the lower one, so that the tears can no
longer  reach  the orifice, and of course cannot enter  the  canal.  In
ectropium, this displacement is of common occurrence, and its treatment
resolves itself wholly into that of the former affection.  But there is
another form of displacement, in which "the lid is either in natural con-
tact with the globe, or only slightly recedes from it in certain positions,
as  when the eye is turned upwards.  The natural prominence on which
the  puncture  is placed, is, however, wanting, and instead of it, here is
a  flattened or rounded cutaneous surface, on which the orifice may be
discerned  (though with difficulty) at a little distance from the mucous
surface  of the lid, and much  reduced in size, being in fact never wetted
by the tears, but dry and contracted."   When discovered, a probe may
be easily introduced through  the orifice and into the sac, which is empty,
showing the integrity  of the apparatus, except as regards the puncture.
This displacement may be caused, either by chronic inflammation of that
part of  the conjunctiva lying near the puncture, or by a chronic affection
of the skin of the lower lid, somewhat resembling eczema, by which a
general  but moderate contraction is produced, and the puncture drawn
outwards.  The treatment recommended  by Mr.  Bowman,  is  to slit
the canal from the puncture  to such an extent as to carry back  the ori-
fice to that part of the conjunctival surface where the tears are collected.
He has  found that the tears are readily  taken up by the new orifice.
Mr.  B. Bell and Dr. Jno. Neill, have repeated Mr. Bowman's operation
with similar success; (vid. Lawrence  on the  Eye, by Dr. Hays, ed.
1854, p. 911.)
                           EPISPADIAS.

  Under  this head, we find in the Brit. For. Med-Chir. Rev. for Jan.
1855, some interesting observations by M.Nelaton,which were originally
published in the " Gazette  Hebdomadaire."   He remarks, that epispa-
dias is a fissure of the corpora cavernosa, just as hypospadias is a fissure
of the corpus spongiosum, or nymphae masculinse.  But as the corpora ca-
vernosa and the pubic symphisis form parts of  the same system, the de-
ficiency in one implies a corresponding deficiency in the other; and so it
can be readily understood how, with a little  further arrest of develop-
ment, epispadias may pass into extrophy of the bladder.  A Swede, set.
20, who came from Stockholm with the express  purpose of putting himself
under M.  Nelaton's  care, presented the following appearances : " The
separation of the two corpora cavernosa left  upon the upper surface of
the penis  a shallow urethral gutter,  covered by a highly sensitive mucous
membrane, and terminating  posteriorly in a rounded  funnel,  on a level
with the  lower border  of the sub-pubic ligament.   The pubic bones
were  one inch apart.  Deeply  seated at the bottom of the  funnel
was the urethro-vesical orifice. The patient wore an apparatus to retain
the urine  during the day; at night time, in  spite of the contrivance of a
funnel passing through the mattress, he lay constantly in a sort of urinal:
his sufferings may be readily imagined."  M. Nelaton operated in the fol- 
868
NEW ELEMENTS OF  OPERATIVE SURGERY
  lowing manner.  He formed, at the expense of the skin of the abdomen
  immediately above the urethral infundibular, a quadrilateral flap, as wide
  as the penis, and rather longer than the organ.  He dissected it off, so
  as to leave it attached at its inferior border by a broad pedicle, corres-
  ponding with the inter-pubic ligament.   Thus he formed a large cutane-
  ous flap, with which  he proposed to close the urethral gutter.   The next
  step consisted in attaching the edges of the flap to the penis.   M. Nela-
  ton made, on either side of the  penis, on its upper surface, at the junc-
  tion of the skin with the urethral mucous membrane, an incision extend-
  ing to the base of the glans.  Two short transverse  incisions, at the ex-
  tremities  of the preceding, enabled him to dissect back flaps a third of
  an inch broad,  destined to overlap and hold in  place the large piece of
  integument to be brought down  from the abdomen ; the raw surfaces of
  the two flaps formed  on the penis would then correspond with  the raw
  surface of the abdominal flap.  This having been effected, and the parts
  united by harelip  pins and sutures,  two  longitudinal incisions  were
  made through the integument of the under side of the penis, that the
  skin of the organ might be loose, and not drag on the raw edges of the
  wound above.   At the end of three days the sutures  were removed ; the
  edges  gaped a little,  but were  soon filled up by granulations.   At the
  end of a month the  urethra was quite closed, but was wide enough to
 admit the  introduction  of the finger.   To rectify this condition, and to
 promote contraction of  the urethra, M. Nelaton employed repeated cau-
 terizations on the inner surface of the new skin, care being  taken to
 avoid burning the mucous membrane.  At the end of the eighth or tenth
 day, when^ the  eschars  were about to separate,  M. Nelaton made lon-
 gitudinal incisions to favour contraction, and by these means a state of
 parts was  produced,  which may be  described  as follows:  The patient
 still suffers from polyuria, but he can hold his water when he is  in bed ;
 secondly, when he is seated; thirdly, when  he is  upright  and  making
 no effort.   When walking, he wears the  ordinary caoutchouc apparatus.
 A similar operation, with beneficial  results, was performed  by the same
 surgeon, in 1852, upon  another young  man, in a yet more deplorable
 condition.
  Operations undertaken for the relief of congenital  deformities of the
 urinary organs in the  male do not always, however, terminate in so fa-
 yourable a manner.   Professor  Denonvilliers operated, September 1,
 1853, in the  Hopital  St. Louis, upon a  young man suffering from both
 epispadias  and  an imperfectly-closed bladder.  An attempt was made
 first to fill up the vesical opening with a  flap of integument from  the ab-
domen, and then to form an urethra  by a portion of the scrotum;  but,
in a  few days, symptoms of peritonitis supervened, and the patient died
within a week of the performance of the operation.
                  FISTULA, RECTO-VAGINAL.

  Dr. Garland, of New Hampshire, in a communication to the  N  H
Journal of Medicine, May, 1854, recommends the following method of
operating in cases of this affection: 
AMERICAN APPENDIX.
869
  "Having previously prepared the patient by the use of gentle laxatives,
(sufficiently active, however, to keep  the bowels  in a soluble condition
for several days,) a full dose of opium should be given, the  parts well
cleansed and  washed with some slight astringent.   The operation may
be commenced by placing  the patient in the  position for lithotomy, ex-
posed  to a strong light; the Speculum Recti  (see cut,) is introduced
through the anuslnto the rectum with its ununited edges looking toward
the vagina. It will be seen that this instrument is a bi-valve, or finestral
speculum, so constructed as to be capable of being fixed by a graduating
arc and screw at any degree  of lateral extension.
  The single blade vaginal speculum, Fig. 2, is next introduced into the
vagina with its handle resting against the pubis.  This being held by an
assistant, who  at the same  time extends  the labia on either side, the
recto-vaginal septum is exposed to view,  and  the operator is able to
jud^e of the extent to which the blades of the speculum recti should be
opened.  When these instruments  are properly fixed and the perineum
drawn a little down or forward, the fistula of laceration is brought plain-
ly to view.  Extension  and counter-extension  is then  made  upon the
walls of the laceration, by passing the instrument fig. 3, (which describes
itself) through the speculum recti to the posterior extremity of the open-
ing, fixing  its concave end  at the angle, the handle  being held between
the second and third fingers of the left hand.   This is pushed forward,
while extension is made by the left index finger, or a blunt hook passed 
870            NEW ELEMENTS OF  OPERATIVE SURGERY.
behind the perineum when that partis not torn away, and by rat-toothed
forceps where perineal laceration exists.
                               Pig. 3.

  The edges of the opening being thus put upon a firm stretch, and re-
moved by means of a small, lance-pointed, double-edged blade, connect-
ed somewhat in the form of a tenaculum to a shank  four or five inches
long,  terminated by a straight handle  (fig. 4,) which is to be  passed
along the speculum recti to the posterior  angle of the laceration, when
it is made to perforate the recto-vaginal septum two lines from the edge,
and close to the counter-extender.  A slight up and down motion is then
given to the knife, while it is drawn carefully forward to the anterior
angle of  the opening, dividing merely the rounded edge, which need not
be separated at either extremity until the cutting is done on the opposite
side, when the  angles can be divided and  the divided part taken out
entire, provided the knife is very thin and of a proper width, say three
lines.
                               Fig. 4.

  Where the fistulous opening is round, the knife should be passed through
the recto-vaginal septum at such distance from the posterior edge as may
be necessary  to form sufficiently acute angles, and give it the "button-
hole" shape.   In such a case the posterior wall of the opening should be
held by  a common tenaculum while a  perforation is made, when the
counter-extender is to be placed in the same manner, and the  freshening
done as described above.  A knowledge of the anatomical structure of
the recto-vaginal septum will at once point to the  necessity of firm ex-
tension, in order to prevent the part from yielding to the pressure and
force of the knife.
                               Fig. 5.

  Alter accomplishing this first step of the operation, which may oe prop-
erly regarded the most difficult, and on which its success mainly depends,
the edges, after all bleeding has ceased, (and it will be well to notice here
that during the operation the surgeon is not annoyed by the considerable
bleeding which always attends  it, as the blood drops directly into  the
speculum recti, and can be washed or wiped away with great facility,)  are
to be approximated by  interrupted sutures introduced by the needle, 
AMERICAN APPENDIX.
871
(figure 5) which, being armed with a waxed ligature, is passed along the
speculum recti, its curve resting on the bottom.  The speculum recti
should be  so adjusted as to allow the needle  to be inserted full one
quarter of an inch from the edge of the opening.  The first suture should
be introduced quite near the posterior angle, the parts being kept tense,
as when the freshening was done.   It will not be found necessary to use
forceps to  confine the part through which the needle is passing, if the
walls are drawn  sufficiently tense by  the extension described above.
After being pushed through the septum, the needle is relieved of its thread
by long  pointed forceps, or  a tenaculum, and  withdrawn to be armed
again  and used  in the same manner on the  opposite side, taking special
care that it is introduced precisely opposite the former  and a.t an equal
distance  from the edge.   All additional sutures are to be introduced in
the same manner, and secured by a knot  made with forceps, or the " lead
bead."
  It sometimes  happens  when a laceration is caused by labor, that, on
reaching the sphincter ani the rent takes  a lateral or transverse direction.
In such a case the operation must be terminated as in transverse fistula,
where  the knife  edges and needle eye are turned half round in the instru-
ments to be used, as in figures 6 and 7.
                               Fig. 7.

  Even where the transverse laceration is extensive, the transverse knife
can be easily used by rolling the speculum from side to side, as the knife
advances.  I have not deemed it necessary to give any description of the
knives  or  needles, as the cuts show for themselves; but it will be well
to have their curve such as will pass with a little  play in the speculum
recti when its blades are closed, as the septum will depend slightly over
the edge of the speculum blade, when the sutures are introduced.
  A laceration, or fistulous opening, treated as I have described, will not
be  effected in the  least by leucorrhoeal or other secretions, when well
done, as the edges, when  smoothly incised  and in exact contact, and
smeared as they will be with plastic lymph, will be entirely impervious
to them, as the cases where I have used this method and these instruments
fully demonstrate.
  I will report the most important facts of one case.   Mrs  -------, at
the age of forty-one, was  delivered  of her first child, some two  years
since.   A  few days  after  her confinement, her physician made  the as-
tounding discovery that her uncommon severe labor had  produced a la-
ceration of the recto-vaginal septum, extending longitudinally from the
perineum upward over three inches.   Every  precaution was taken im- 
872
NEW ELEMENTS  OP OPERATIVE SURGERY.
 mediately, by regulating the  bowels, keeping  the  parts clean and  the
 patient quiet; but not the slightest improvement was made in the size of
 the opening.  The entire discharges from the bowels passed through the
 vagina.
    I operated a few months since, assisted by Dr. F.  B. Ayer, using  the
 method and instrument described in this brief communication.  The  pa-
 tient was suffering at the time from uterine and vaginal leucorrhoea; and
 to add to this unfavorable circumstance, a catamenial discharge made its
 appearance in eight hours after the operation  was  performed ; but not-
 withstanding all this, the parts  united  save a small  opening near  the
 sphincter ani, where a portion of  the septum was  much thinned down
 and removed by ulceration.   Granulations were  kept alive by the appli-
 cation  of nitrate of silver, until the fistula closed.  The bowels were  not
 moved for ten days, and then only once a week  during the  application
 of the  nitrate.  I do not apply  the caustics in such cases oftener than
 once a week, as a more frequent use will defeat  the object aimed at by
 destroying the delicate and but imperfectly formed  granulations."
   Dr. G. does not refer to the use of the  " clamp-suture," employed by
 Dr. Sims, but we believe there is but one opinion among those who have
 tried it in  recto or vesico-vaginal fistula, as to  its superiority over all
 other forms of suture.  Professor Mussey has reported a case of the for-
 mer in  the American  Journal of  Medical Sciences,  for October, 1853,
 in which he found this suture of the greatest service.   Prof. M. attaches
 much  importance to the regimen  adopted during the  after  treatment.
 The diet, in his case, was spare and unstimulative.  Up to the eighteenth
 day, the patient lived on from 2 to 21 ounces of crackers a day, and the
 bowels  were kept constipated for 24 days.

                      Fistula, Vesico- Uterine.

  In 1852, M. Jobert's Traite des Fistu/es Vesico- Uterines, Vesico-
 Utero-Vaginales, Entero-Vaginales, et Recto-Vaginales, appeared  at
 Paris, in which, he enters into the  consideration of the nature and treat-
 ment of several lesions of the  genito-urinary apparatus which have been
 but little noticed by the  obstetrical  or  surgical writers.   But as it is
 chiefly with the  treatment of vesico-uterine fistula, that we are now con-
 cerned, we will briefly analyze the results of  M. Jobert's experience
 After alluding to the ineflicacy of  cauterizing agents,  in consequence  of
 the loss of substance  which generally accompanies  this accident, he as-
 serts that it is only by the knife, and the  suture, that  the surgeon can
 hope to effect a cure.   His first patient, in whom the anterior wall  of
 the neck of the uterus  and  the corresponding  portion of the bladder
 were entirely destroyed, was operated on, October 24,1849, in the pres-
 ence of MM  Capuron, Depaul  and others.  The  neck of  the uterus
 having been dragged down by a double hook inserted into the os tinea?
 two incisions were made  on the borders of the  fistulous  opening, in the
 direction of  its commissures, and in incising the uterine orifice,  the
vagina was detached in a lateral direction.  The neck of the uterus was
Ireely opened, which enabled the operator  to make bare the ed^es  of
tbe  fistula to remove  the  firm excrescences, and the  utero-vesicd mu-
cous membrane.  The lateral incisions then permitted the vesical open- 
AMERICAN APPENDIX.
873
ing to be brought together, and the suture to be applied.  The latter was
the most difficult part of the operation, but was greatly facilitated by
the free incisions made at the point of junction of  the vagina and neck
of the uterus, both at its anterior and  lateral portions.  Three sutures
were employed.   But a single artery required the ligature.  In the course
of the day a copious discharge of blood  followed the separation of this
ligature.  In the evening the patient suffered  from  colicky pains, retch-
ing, &c., and the abdomen  became somewhat  tympanitic.  But these
symptoms gradually disappeared, and on the 2d of  November, nine days
after the operation, the parts were examined with the  speculum, and an
injection of warm water thrown into the  vagina.  One of the sutures was
removed.  The  catheter  brought away fetid urine.   The evacuation
finished with those rapid and interrupted jets, which accompany this act
in its  normal state, denoting  that  the  functions of  the bladder were re-
established.   On the 5th of March, 1853, the patient remained perfectly
cured.  M. Jobert asserts (p. 55) that he has met with a  considerable
number of cases of vesico-uterine fistula,  but they were not all similar to
that above mentioned, as with the anterior wall of the neck of the  uterus,
there  was more or less destruction of the vesico-vaginal septum, on which
account they were more properly cases  of vesico-utero-vagiual  fistula.
In concluding his remarks upon the above case, M.  Jobert observes, that
according to  his experience, if the sutures are permitted to remain too
long in contact with the  tissues  the urine is apt to form a passage by
their side.

                   Fistula,  Vesico- Utero- Vaginal.

   M.  Jobert claims to  be the first to  describe this affection, which he
asserts  is nearly always produced by the sloughing which  results from
the pressure of the head of the  foetus, or  by the instruments employed
in the extraction of the child.  The principles of  treatment applicable
to the vesico-vaginal fistula,  are alike applicable here.  There is, how-
ever, this difference, in the former malady, a portion of the vagina re-
mains  attached to the cervex uteri, but in the latter, this is wanting.
In the former, the bladder and vagina  furnish materials  for reparation,
but in the latter these require to be borrowed from adjacent parts.  In
the vesico-utero-vaginal  fistula, likewise,  neither  the  uterus nor  the
vagina can be made to prolapse ; the  operation must therefore be per-
formed on the parts in situ, and will severely tax the surgeon's  patience.
   M.  Jobert, gives the details of four cases in which he operated  for the
relief of this affection, in one of which  the proceeding was attended with
fatal results.  This case may be found  reported at page 98, of his re-
cently published work.  For the particulars of the  operation performed
by M. Jobert in these cases, we must refer to the  work itself, and can
only mention, that  he  resorts to autoplastic par glissement,  and free
lateral incisions into the vagina, &c, &c.

                       Fistula, Vesico- Vaginal.

   During the past five years two important contributions  have been made
to the treatment of this distressing affection, viz. the  Traite de Chirurgie
   vol. in.                      110 
874             NEW ELEMENTS OF OPERATIVE SURGERY.

Plastique. of M. Jobert, (tome second, pp. 266-712) and the Monograph
of Dr. J. Marion Sims, which appeared in the American Journal of Med-
ical Sciences, January, 1852.  Although the latter comprises but twenty
eight  pages, we venture to  assert that the surgeon will find in it more
practical'information than canbe gathered from the more elaborate treatise
of M. Jobert.   Iudeed, we may affirm without fear  of contradiction,  at
least from any American surgeon, that  the method proposed by Dr Sims
forms a new era in the history of  this hitherto most unmanageable affec-
tion, and we shall endeavour to give  such a synopsis of his views, as to
render  the proceeding  adopted by him, intelligible to the reader.  Dr.
Sims claims originality ; 1st.  For the discovery of a method by which
the vagina can be thoroughly explored, and the operation easily  per-
formed.
   2d. For the introduction of a new suture apparatus, which lies  in the
tissues for an indefinite period, without danger of cutting its way out,  as
do silk  ligatures.  3d. For  the  invention  of a self-retaining catheter,
which can be worn with the greatest comfort  by the patient during the
whole process of treatment.
   " The patient is placed upon a table about 21-2 by 4 feet, on her knees,
with the nates elevated, and the  head and shoulders depressed.  The
knees must be  separated some 6 or 8 inches, the thighs  at about  right
angles with the table, and the clothing all  thoroughly loosened, so that
there shall be no compression of the .abdominal  parietes.  An assistant
on each side lays a hand in the fold between the glutei muscles and the
thigh, the ends  of the fingers extending quite to the labia majora ; then,
by simultaneously pulling the nates upwards and outwards, the os  exter-
num opens, the pelvic and abdominal viscera all gravitate towards the
epigastric region, the atmosphere  enters the vagina, and  there, pressing
with a weight of 14 lbs. upon the square inch, soon stretches this canal
out to its utmost limits,  affording  an  easy  view of  the os tinea?, fistula,
&c.  To facilitate the exhibition  of the parts, the assistant on the right
side of  the patient introduces into the vagina the lever speculum repre-
sented in Fig. 1, and then  by lifting the perineum, stretching the sphincter
and raising up the recto-vaginal  septum, it is as easy to  view the whole
vaginal canal as it is to examine the fauces by turning a mouth  widely
open, up to a strong light.   (See Fig. 4.)  This method of exhibiting the
parts  is not only useful in  these cases, but in all affections of the  os and
cervix uteri requiring ocular inspection.  The most painful  organic dis-
eases,  such as corroding ulcer, carcinoma, &c, may be thus  exposed
without inflicting the least pain, while any local treatment may be insti-
tuted without danger of injuring the healthy structures.   By this method
also, a proper estimate, anatomically, can  be had  of the shape and capa-
city of  the vagina ; for where there is no organic change, no contraction
and no rigidity of it from  sloughs, ulcers, and cicatrices, and where the
uterus is movable, this canal immediately swells  out to an enormous
extent, thus showing its great expansibility.
   Fig. 1 represents the speculum.  When introduced and held properly,
it causes no pain whatever.   It is well enough to have two or three of dif-
ferent sizes, so as to be prepared for any case.   The one ordinarily used by
me is about 2\ inches from  a, where it supports the sphincter, to its ter-
minal extremity at b.  Its concavity c, c serves to  reflect a strong  light 
AMERICAN APPENDIX.
875
down on the vagino-vesical septum, the seat of fistula.   Its  breadth from
d to e is about fths of an inch, widening a little as it approaches the end,
making it somewhat in the shape of a duck's bill.  The handle is made
strong and unyielding, because a considerable degree of leverage has to
be exercised by it.   The curve at/, being cushioned to prevent its hurt-
ing the forefinger, tits accurately over it.   The whole instrument is made
of  German silver  the  concavity being highly polished for reflecting  the
light.                                                          °
                        FiS- *•                        Fig. 2.
   A small, slightly convex spatula, Fig. 2, (of German silver,) may occa-
sionally be needed to press the urethra downwards against the symphysis
pubis, when  there is a very  minute fistula in the neighbourhood of the
trigonus vesicalis ; particularly if the urethral folds are very redundant.
This will seldom be used, but is sometimes indispensable, not only in ex-
ploration, but in holding the  healthy parts out of the way in passing su-
tures.
   These simple instruments, with  this position and a good light, are all
that are  necessary  for obtaining an accurate view of the parts.   If the
vagina and outlet are ordinarily capacious, a good strong northern light, of
a clear day, from a large solitary window, is all-sufficient.  But if this ca-
nal has been narrowed by cicatrices  after extensive sloughs, or from other
causes, then sun-light is absolutely  necessary for every stage of  the op- 
876
NEW ELEMENTS  OF OPERATIVE SURGERY.
eration from first to last.  For this purpose, a small table is  placed near
a window admitting the sun-light.  An assistant, sitting by, adjusts on
the table a glass, Fig.  3, some  eight or ten  inches in diameter, so as to
throw the rays of light into  the  vagina, which, passing to tho right of
the operator, and  striking the  concave surface of the bright speculum,
are reflected down on the anterior vaginal paries, making everthing per-
fectly distinct.
Fig. 3.
  Fig. 4 shows the speculum introduced, elevating and supporting the
sphincter;  also the relative position of the organs, when the patient is
examined as directed; the vaginal canal being distended to its greatest
capacity.
   Of scarifying the edges of the fistulous opening.—This was the most
tedious and difficult part of the operation with me, as it has always been
with others.  For three or  four years,  I had great trouble in getting
such instruments  made as I  thought indicated; but those I now use for
this  purpose  are so simple, that they  can be had  anywhere.   A deli-
cate tenaculum, Fig.  5, a,  and a sharp-pointed knife, Fig. 5, b, are alone
necessary.
  The tenaculum, Fig. 5,  a,  is very small; the curve being at right an-
gles with the shaft, and not  more  than  Jd of an  inch lono-.  If longer
it is not easily managed, nor so generally applicable to any and every part
of the fistula.  The shaft,  some five or six inches long, is set into a firm
handle.  Of this  size and shape, it can be used to elevate  the edge of
the opening with equal facility,  whether laterally or otherwise ; while
if curved at more than a right angle, it can be useful only in hooking up'
and drawing forward the  anterior and posterior margins
  Fig. 5 represents the tenaculum a, hooking up and  elevating the edge
of a fistula, while the point of the  knife b is applied, ready to separate the
part so raised up   This process is continued till the edge of the opening
is well vivified all round (as seen by the dotted line), sometimes removing
a strip an inch or more long  before it is cut or torn off.  The  denudation 
AMERICAN APPENDIX.                     877
is to be from a quarter to the third of an inch wide.   I have often made the
mistake of not removing enough of the callous edge; but I now take good

                                Fig. 5.
care to remove it freely, extending the scarification up on the vaginal sur-
face.  I do not remove any of the lining membrane of the bladder, unless
it is very much altered in character, and projects through the fistula into
the vagina in such a way as to obstruct the easy performance of the opera-
tion, which rarely happens, and only where there is a great loss of substance.
  Where  the fistula is very small, say not larger than a common-sized 
878            NEW ELEMENTS OF OPERATIVE SURGERY.
 probe, or even as small as a number  seven or eight  sewing needle, the
 best plan to  scarify is, to hook up the part with the tenaculum, pull it
 forward, and by a thrust of the knife  transfix the entire thickness of tho
 vagino-vesical  septum; then by a circular sweep of the instrument, the
 whole fistulous track may be removed at once ;  which substitutes for the
 small and  callous opening,  a  smoothly cut  orifice  of rather a conical
 shape, large enough to admit the end of the forefinger.
   Where the fistula is so small, there is always an abundance of tissue,
 and there need be no fear  of removing the parts freely ; for it is easier
 to close properly an opening as large as the end of  the  finger, than a
 smaller one, provided there is no scarcity of texture.
   vjg. 6.      Where the fistula, on the other hand, is very large, thero is
          occasionally some trouble in determining exactly what to cut;
          because by the bearing down, sobbing, straining, or even vol-
          untary resistance of the patient,  the  mucous membrane of the
          bladder may be forced out in voluminous folds, so as to ren-
          der the fistulous edges indistinct, and there is danger of scar-
          ifying, either too high up on the vaginal  surface, or too far
          in on the vesical lining.  To obviate this difficulty, a properly
          curved  metallic bougie  may be passed through the urethra
          up to the fundus of the bladder; thus  putting the  parts on
          the stretch and carrying back into its cavity, the  apparently
          redundant lining.  The bougie curved down between  the
          thighs may be held by a third assistant.  But I greatly prefer
          to introduce a bit of  soft  sponge, of proper  size,  into  the
          cavity of the bladder, which forces back the lining membrane,
          leaving the  fistulous boundary distinct, when the scarification
          may be  easily  accomplished.  The introduction of the sponge
          into the  cavity of the bladder, or merely between the edges
          of the fistula, as well as its removal, is always  attended with
          very great pain.  Once introduced, I allow it to remain, till
          the sutures are passed and  ready to be secured.
            During the scarification,  there is, of course, always hemor-
          rhage ; and, in some instances, it is so profuse as to compel
          us to desist  for  a short  time, the patient  being allowed to
          change her position and rest.  As soon as the bleeding ceases,
          the operation may be resumed.
            To remove the blood from the cut  surface during the scar-
          ification, a probang is necessary (Fig. 6), which is  made by
          tying a nice bit of sponge to the  end of a piece of whalebone
          some eight or ten inches long.  It is well enough to have two
          or three of these, which will keep one assistant  pretty busy to
          wash clear of  blood at this stage of the process.  The pro-
          bang  can generally be best applied by the operator, as his
          position allows him to see exactly where it is most needed.
  I cannot lay too much stress on the  great necessity of perfecting  well
this part of the operation ;  for, upon a proper and free denudation of the
fistulous orifice, success or failure will mainly depend.
  Sometimes one edge of the fistula is thinner than  another.   Velpeau
and others have noticed this  fact;  but in not a single instance  have I
found (as they did) the thinner edge behind and the thicker before. Where 
AMERICAN APPENDIX.
879
 there was any appreciable difference, the  reverse was  the fact in every
 case that I have as yet examined.  This  thinning of the anterior edge,
 where it was right at the neck of the bladder, was always  a'erious ob-
 stacle to the proper closure of the fistula.  By giving  way  too  soon, it
 almost invariably left an  opening at the point of its greatest thinning."
   Dr. Sims employs the clamp suture, composed of small annealed silver
 wire fastened to cross-bars, after the manner of the quilled suture.  The
 wire is drawn down to about the size of a horse-hair, and then annealed.
 The cross-bars,  or clamps, are very small, not more than a line in diam-
 eter, and  made of silver or lead, as most convenient.  If of silver,  they
 may be tubular; when of lead, solid.  "They must be highly polished,
 and without the slighest  asperity, particularly  at  their  extremities.
 They act as clamps in this way.   The parts embraced between them, be-
 ing held in close apposition, swell  upward,  and overlap them; while
 they, by pressure, produce an ulceration in the vaginal  surface, sufficient
 to allow of their being perfectly embedded, and after a while even some-
 times hidden from view.   This ulcerative  process is attended, of course,
 with  a purulent discharge, which, continuing for three  or four days,
 diminishes,  and  soon ceases  altogether; but not till  the bed made by
 the clamp becomes lined with mucous membrane.  After this the appa-
 ratus would  lie  innocuously in  the  tissue for an indefinite period.  I
 have allowed it to remain long enough for the extremities of the clamps
 to be covered over completely by firm granulations, which, opposing con-
 siderable  resistance to their removal, had to be  lacerated before  this
 could be accomplished.
   This suture is far preferable  to  any thing  before suggested  for the
purpose.  Its introduction dates from June 1849,  since which  time I
have had comparatively little trouble in the treatment  of the  great ma-
 jority of  cases of vesico-vaginal fistula.   Properly applied, this suture
never ulcerates out, having always to be removed by means of scissors,
hooks, and forceps.  It may be allowed to  remain intact  for six, eight,
or ten days, or even longer.  If removed  too soon, the delicate cicatrix
may gradually yield to the traction of the  ascending  uterus, or to the
force exerted by the bladder in  expelling its  contents, and  thus  repro-
duce a small fistulous orifice to be closed by a subsequent and more  cau-
tious operation.   I have seen the new cicatrix give way from another
cause, and perhaps it  is the chief one.  The clamps,  burrowing in the
vaginal surface, leave a deep sulcus or fissure on each side of the  new
cicatrix, which,  when they are removed too soon, fill up by granulation.
It is a law of all granulating wounds  to contract as  they  heal, and this
contraction on each side of the new cicatrix is often sufficient to pull it
gradually apart.   But if the clamps are allowed to remain till their sulci
are covered with mucous membrane, then there is no danger of  this ac-
 cident,  for these chasms then gradually disappear, less  by filling up with
 granulations, than by an absorption of their elevated edges.
   Accidents of this scrt have  happened repeatedly in my hands, from a
 too early  removal of the suture apparatus.  Great judgment, which ex-
 perience alone can give,  is necessary to  determine the length of time
 that the sutures ought to remain intact, for no positive rules can be  laid
 down that will answer invariably in every case.
   I have also seen serious mischief result from  leaving the clamps too
 long embedded  in the  parts.  Their burrowing and  ulceration may ex- 
880
NEW ELEMENTS  OP OPERATIVE SURGERY.
tend entirely through the vagino-vesical  structure, thereby substituting
new fistulas openings for the original one.  This  complication is by no
means incurable, but only prolongs the treatment, and postpones ultimate
success.
  In two or three instances I have witnessed  a still more serious acci-
dent from an undue pressure  of the clamps, viz. a  strangulation of the
enclosed fistulous edges,  which unfortunately resulted in a  sloughing
of the tumefied parts, and a consequent enlarging of the opening.  In
no  instance, however, has this accident rendered  the case hopeless, or
even caused me to feel any concern either for the  immediate safety of
the patient,  or for ultimate success in treatment.
  After the scarification is completed, the patient is allowed to rest for
a few minutes before the introduction of the sutures ; an operation which
is somewhat  tedious, but not  difficult.   The number of sutures will de-
pend  on the size of the fistula.   Less than two will not  suffice  for the
smallest opening ;  while the great majority of cases will require  three ;
and occasionally, we meet with one sufficiently  large to  demand four.
  The needle which I use is represented by Fig. 7.
It is  awl-shaped, and spear-pointed, with the eye
near the point.  The shaft is about six  inches long ;
the part near the  handle is made malleable, allow-
ing it to be bent into any desirable shape for the
purpose of preventing the hand, as it grasps the han-
dle, from obstructing the view of the operator.
  To illustrate the method of suture, let  us suppose
a case,  where the fistula is oval, transverse, occupy-
ing the bass-fond of the bladder, about half way be-
tween the urethra and os tinea?, in the  mesial line,
and large  enough to admit the end of the index fin-
ger.  This, in shape, size, and position, is altogether
the most  favourable case that can occur, both for
a neat performance of the operation, and for certain-
ty of success.  Such a fistula will require three su-
tures

                     Fig. 8.
Fig. 7.
 _ Fig. 8 represents  them introduced at  proper intervals; the two out-
side ones passing within a fourth of an inch of  the angles of the fistula. 
AMERICAN APPENDIX.
88J
The middle one is first applied.   The needle, armed with a silk thread,
is entered about half an inch anterior to the  scarified edge of the fistu-
la; pushed deeply into the vesical septum, without transfixing it; brought
out just at the edge of the mucous lining of the bladder ; carried across
the opening; made to enter the  opposite side at a point corresponding
with its direction anteriorly, observing the same precautions in its course;
while it is brought out on the vaginal surface about half an inch beyond
the scarified part.
  The passage of the needle through the anterior edge of the opening is
easy enough; but the loose and yielding nature of the posterior, renders
some support  necessary before it can be made to appear on the vaginal
surface.  For this  purpose a blunt hook (Fig. 9, a) is placed flatwise,
just beyond the spot at which we intend  the needle to come out, thus
making a fixed point for it, when it passes with great ease.
  Fig. 9, b, shows the needle armed and passed  as directed: the spear-
point having emerged at its proper place on the distal side of the fistula,
is supported by the blunt hook, a, over which it rests.
Fig. 9.                                          Fig. 10
 
882
NEW ELEMENTS OF OPERATIVE SURGERY.
Fig. 11.
   As soon as  this  is accomplished, the blunt hook is laid aside, and a
small tenaculum (Fig. 10, a) used to hook up the ligature which lies close
by the side of the needle, b.  There is sometimes a little delay in doing
this, particularly if the  parts are too contracted, or  the light not good.
In this case, the needle should be pushed an eighth or  a fourth of  an inch
further on, and  then  retracted as much, when a  little loop of ligature
will be left, into which the tenaculum can be passed.  (Fig. 10.)   After
this, the needle is to be  withdrawn entirely, leaving the  ligature  in situ,
with its distal end or loop securely on the hook.  The hook is then drawn
out, and with it, of course, the ligature, the two ends of which are  now
hanging from the vulva.   The other ligatures are passed in like manner,
observing the precautions already laid down.*
                         In  pulling  on  the  distal end  of the ligature,
                       another expedient is  necessary  to prevent  the
                       cutting and  pain, which would inevitably attend
                       its passage over the posterior edge of the fistu-
                       la.  For this, a  crescent shaped fork (Fig. 11)
                       mounted on a shaft of convenient length, is pass-
                       ed up, which, pushing the ligature above  its fur-
                       thest point of exit, serves the purpose of a pul-
                       ley ;  when it (the ligature) can  be easily drawn
                       backward  or forward by traction on either end,
                       without  inflicting the slightest injury on  the
                       part, or pain on the patient.
                         Having now given directions for passing the
                       ligatures, let us suppose that we have introduced
                       the three, or as  many as we want.   The difficult
                       part of the operation is over, and  we have only
                       to substitute the  annealed silver  wires for the
                       silk ligatures ;  which  is the  work of but a few
                                              minutes.  Take a piece
                                             of the  wire  twelve or
                                             eighteen   inches  long,
                                             making  a small crook
                                             at one end so as to  fas-
                                             ten it securely  to  one
                                             of the ligatures. Fig. 12
                                             shows the  wire crooked
                                             and hanging to the end
                                             Ci" iLo thread; the other
                                             end of the thread being
                                             pulled on  till  it  comes
                                             out leaving the wire in
                                             its place.  In the same
                                             way we  replace the re-
                                             maining  silk  ligatures
with silver wire ;  both ends of which project from the vulva, the proximal
directed downward, and the distal held upward.

  * The ligatures cannot always be introduced with as little trouble  as in the case iust sun-
posed.  For instance, when  the loss of substance is very great, the fistula is so w?deJ that £
Fig. 12.
 
AMERICAN APPENDIX.                       883
   The next step is to secure them by means of the clamps.  In Fig. 13
the wires are represented passed  the two ends of each  brought  out of
Fig. 13.
     Fig. 14.


I—___0
 the vulva ; the distal a, a, a, to the left;  the proximal b, b, b, to the right.
 The  distal ends are passed through small oblong holes made in the silver
 or leaden bar c, to  suit  the  distances between the  points of  suture at
 d, d, d.   The  wires may be fastened to the  bar or clamp c, by being
 turned  twice  around  it, or by being  passed  through a perforated shot
 and  bent over  it.  This done,- we now pull  upon  the proximal  ends
 b  b b, and,  as a matter of course, the bar c is carried into the vagina,

 needle cannot be  made to traverse both sides of it  at once ; hence, it becomes necessary to
 hook up the ligature as soon as the needle has pierced the  anterior border of the opening ;
 when it is withdrawn, re-threaded with the distal end of the same ligature, and passed through
 the posterior edge.  In re-threading the needle, care must be taken to pass the thread through
 the eye from its upper or  concave surface ; otherwise, when it is withdrawn, it will be found
 still hanging to  the main thread that is stretched across the fistula, instead of slipping  easily
from its free end :  which  is a very awkward accident, inasmuch  as the patient  is subjected
unnecessarily to the pain and delay of having it introduced again 
884             NEW ELEMENTS OP  OPERATIVE SURGERY.
op above  the  fistula, and made to occupy a bed  right over the orifices
d d d.  Here, the crescent-shaped fork is supplanted by a modification of
it, Fig. 14, broad enough to serve the purpose of a pulley for all three
of the wires.   The next step is to pass another bar or clamp on the prox-
imal ends of the wires, and to push it along them into the vagina, till it oc-
cupies a position in front of the fistula, corresponding  exactly with the
one behind it.
  Fig. 15  shows  the two  clamps, one on each side of  the  fistula,  and
everything ready for closing it.  The  proximal clamp  is  pushed up by
the crescent-shaped  fork, while the wires are held firmly.   This brings
the denuded edges of the fistula into such close contact that it would be
difficult to enter a common sized probe between them.   The force neces-
sary for tightening the clamps  will depend upon the judgment of the op-
erator ;  not enough will allow the parts to gape,  while too much, which
is the most frequent fault, will produce the  bad effects formerly alluded
to.
Fig. 15.
Fig. 16.
Fig. 17.
  A simple and  perfect contrivance  now serves to hold the clamp3 iu
their proper places.  A small bird shot, perforated, is passed alono- each
wire close against the proximal clamp ; when, the wires being held se-
curely, they are gently but firmly  compressed by means of a long strong
pair of forceps (Fig. 16), whereby they are made to perform the office
of a knot in preventing the clamp  from slipping off the wire.   The wires
are cut off about a fourth or  eighth  of an inch from the shot, and then
bent over, which effectually prevents  their slipping off.
  Fig. 17 shows the appearance of the fistula and suture apparatus after
the operation; the edges of the opening in apposition ;  a clamp on each
Bide >A it;  the flattened shot against  the proximal clamp ; the wires cut
off  j, ad  bent over the shot,  which protects  the recto-vaginal surface
against their sharp ends, as well as prevents their slipping 
AMERICAN APPENDIX.
885
  The operation which may have lasted some twenty or thirty minutes,
or, under any  circumstances, not more than an hour, is now over; and
our patient is ready for bed,  complaining only of fatigue from the con-
strained  position.
  There  is one peculiarity about the instruments, which greatly facilitates
the operation.  For instance, the tenaculum, the needle, the blunt hook,
and the  crescent-shaped fork, have their shafts made malleable, so that
they may be bent in a direction to keep the  hand of the operator below
the axis  of the vaginal canal,  which preserves the line  of vision unob-
structed."
  Dr. Sims, after alluding to  the various plans  devised by surgeons to
prevent the escape of urine through  the wound, remarks: " With me, as
with others, this has been the most serious obstacle to the success of  tho
operation; for, if a single drop of urine finds its way through the fistu-
lous  orifice, it is sure to be followed by more, and thus a failure to some
extent is almost inevitable.
  Knowing that something to draw off the urine continually was abso
lutely indispensable to success, and  seeing that all other operators had
failed to  secure  a  catheter in  the  bladder  by any justifiable external
means, I conceived  the idea of contriving  for this  purpose, a  self-re-
taining instrument."
  At length he hit  upon the instrument represented in Fig. 18.

                               Fig. 18.
  " Fig. 18 is a correct representation of the self-retaining catheter, and
exactly of  the size and shape that is most generally required.   It may
sometimes be curved a little more.   The end c is introduced and lodged
up behind the symphysis pubis; the part from a to b lies in the  urethra;
while the outer extremity d, hangs down immediately below the meatus
urinarius ;  this downward  projection at d serves the double purpose of
preventing it from slipping into the bladder, and of preserving its paral-
lelism.  If this part is too straight, running in the direction of the axis of
the main channel from a to b, the instrument, after a few hours' use, will
revolve on its own axis, and the end c may be turned to one side, or even
so far round as to impinge on the  fistulous opening.  Should this acci-
dent happen, the instrument is not well suited to the case.  It is either
too long, too short, too crooked ;  or, what is more likely, not curved
down enough below the meatus.
   When well  fitted to the case, it can  be worn with great ease to  the
patient; and never turns, nor slips out, it matters  not  whether she lies
on the back or side.   It is perfectly self-retaining, being held  in  the
bladder by an  internal pressure against the symphysis pubis, and by an
external pressure on  the outer end exerted by the  labia overlapping it,
and hiding it entirely  from view.   The  holes should be small, about as
represented in the drawing. 
886
NEW ELEMENTS  OF OPERATIVE SURGERY.
   Thus, I have, as briefly as possible, described the mechanical appara-
 tus  absolutely necessary for the successful treatment of vesico-vaginal
 fistula.
   Of the After- Treatment.—The operation finished, the patient is placed
 in bed, and the catheter introduced into the bladder.  A moment will
 suffice to show the urine leaking from its outer extremity. ^             I
   A large anodyne should now be  given, such as morphia, laudanum,'
 paregoric, or whatever we may  know will best agree with  the  patient.
 The bowels are to be kept perfectly quiescent, till the success or failure
 of the  operation is ascertained.  I have often kept them locked up for
 three and four weeks  without  any bad consequences  whatever to the
 general system.   In but two instances, that I recollect, have I ever per-
 mitted  them to be opened under ten or fifteen days from the time of the
 operation.  This is very easily done.  Previously to the operation  some
 light laxative medicine must be  given :  after it, the diet must be of a
 constipating character.  I generally direct my patients to live on tea and
 crackers, allowing coffee if preferred, and  prohibiting meats, fruits, sac-
 charine substances, and all articles of food made of Indian, or common
 corn meal.   Formerly, I allowed as little water as possible ; but latterly,
 since the introduction of silver  sutures, and  the perfection of the cathe-
 ter, I have not thought its interdiction necessary.   To assist the diet in
 producing constipation I order some form  of opium in as large  doses as
 can  be  borne, at least twice in the twenty-four hours.   Old fistula cases
 are generally used to opium; and where they are not, they soon  learn its
 beneficial effects.   It calms the  nerves, inspires hope, relieves the scald-
 'ng  of  the urine,  prevents a craving for  food,  produces constipation,
  ■lbdues inflammatory action, and assists the patient, doomed to a fort-
  .ght's  horizontal position, to pass the time with pleasant  dreams, and
 delightful sensations, instead of painful forebodings, and intolerable suf-
ferings.
   There is not the least necessity  for the patient's assuming the erect
 posture, even for a moment: thus, by diet, opiates, and quietude, a per-
 fect state of constipation can be kept up  as long as we could  possibly
 want it in any case.   All  this  facilitates  the healing process, which is
 effected by the " first intention ; " or, if it  fail, it does so only at one or
 two points, which may be subsequently closed.
   The  catheter is to be removed as often as necessary to keep it clear of
 concretions  and  mucus, which,  in  a few cases, may be twice a day; in
 some, once; while in others, it  may be allowed to remain two or three
 days, or  even longer.  It is to  be carefully watched, and must not be
 permitted to remain long enough to become obstructed.   I have seen a
 failure  result from a neglect of  this precaution.
   The  patient's comfort is greatly promoted, by washing the vulval ope-
 ning twice a day, or oftener, with warm  or cold water, as may be pre-
 ferred.
   For this purpose a common bed-pan is placed under the nates, as she
 lies on the back:  when the water maybe  thrown into the os externum,
 over the mons, vulva, and inguinal regions, by means of a syringe  hold-
 ing  some six  or eight ounces.   The water has  sometimes to be thrown
 with considerable force to remove urinary deposits from the nates and
 genitals. 
AMERICAN APPENDIX.
887
  The patient may lie on the back, or either side, changing her position
whenever she pleases; but  in no instance is  she allowed to raise up in
bed.
  Some women are more cleanly than others in protecting themselves
and clothing from the urine.  Most of them perfer old cloths to absorb
it, which are changed  as frequently as necessary for comfort.
  On the third or fourth day after the operation, I usually examine the
sutures to see if all is  right.  This must be  done with as little  exertion
on the part of the patient as possible.   On the sixth or seventh, I examine
them again, and if they are doing no mischief, it is much  better not to
remove them till the ninth or tenth day.  The removal of the  clamps is
occasionally  troublesome, but by a little  care  it can be  done with suf-
ficient ease to both patient  and operator.  The flattened shots are first
clipped off, then by a blunt  hook, the anterior clamp is readily elevated
from its bed and removed ; after which, the posterior one, with the wires
attached, may be  hooked up, pushed backwards, disengaged entirely,
and then lifted out with the  forceps.
  This accomplished,  place the patient in bed again, and continue  the
use of the catheter, with the recumbent position, for several days longer,
to prevent any strain or traction on the delicate new cicatrix.
  By allowing the patient to get up too soon, and evacute the contents of
the bladder spontaneously, there is danger of rupturing the cicatrix,  but
by persevering with the catheter and position, till it has  time to become
well organized, there is no danger.  This will take usually fifteen days
from the performance of the operation.
  Dr  Sims, who has  been  compelled by impaired health to abandon
his  late residence, Montgomery, Alabama, has opened  an Infirmary in
the  city  of New-York, intended  especially  for patients afflicted with
the  malady under  consideration.  He has already perfectly cured, by
his very ingenious method, upwards of twenty cases of vesico-vaginal fis-
tula, as well as several cases of lacerated perineum.
  Dr. Wm. H. Mussey, of Cincinnati, has reported in the  Western Lan-
cet for June, 1854, a case of vesico-vaginal fistula complicated with vesi-
cal calculus, in which he operated with success.  The following diagram
exhibits  the position of the fistula, together with the nature and extent
of the operation.  The stone was crushed with the  lithontriptor of M. 
 888           NEW ELEMENTS OF OPERATIVE SURGERY.

 Civiale.   The following were  the  steps  employed to close the fistula:
 " In order that the  patient should have  the  benefit of the anesthetic
 state, she was placed upon her back.  The hips were elevated, an assis-
 tant on either side supported the limbs, and held away the vulva, another
 assistant depressed the perineum ; for these  purposes the instruments
 of Mr. Jobert de Lambelle, (of the Hotel Dieu)  were employed.  The
 mucous surface of the vaginal wall, for half an inch in width around the
 fistula, (including its edge,) was scarified, and the stitches entered one-
 third of an inch from these  scarifications, including the muscular, with-
 out penetrating the mucous coat of the bladder.  The " Clamp Suture "
 of Mr. Sims, of Georgia, was employed to hold the freshened surfaces
 in apposition.   Threads of silk, (five in number) were first passed, then
 the silver wire was drawn through and fastened by means of the perfor-
 ated shot, to slightly curved leaden bars one eighth of an inch in diame-
 ter, the anterior being one and a quarter and the posterior one and three
 quarters inch in length.  An elastic catheter was kept in position in the
 urethra, by means of tapes attached to a band around the body, the ex-
 ternal  orifice  being  depressed by means of a bit of sheet lead, so that
 the urine could not be  conducted  back into contact with  the  wound.
 This was  removed and cleansed  twice a day for three days, and after
 that once a day—the vagina and vulva being  cleansed eveiy day  with
 tepid water, by means of a glister syringe.
  The  patient was kept  on her  back.   On the ninth day the  stitches
were removed, but I was convinced that after the sixth day there was no
tension upon them.  There was a spontaneous  evacuation of the bowels
on the fifteenth day.  On the eighteenth day the catheter was removed,
and the patient allowed to rise.
  On the twenty-seventh day of the operation, the patient returned to
her home perfectly cured, there being no evidence that a particle of urine
had passed the wound since  the day of the operation."
                          FRACTURES.

  The starched, or dextrine bandage so highly recommended by M. Vel-
peau, in the first volume  of this work, does not seem to be very exten-
sively used in the treatment of fractures, either in  this country or in
Great Britain.
  Wire gauze is  now coming into use in London,  for  bandage, cradles,
and splints.   Mr. Startin claims to be the inventor.  Flattened copper or
iron  wire is employed, and the method of applying is first to obtain a
pattern for the splint by means of cartridge-paper, and then carefully to
cut the sheet of gauze to the pattern.   The edges must be cut transversly
at intervals, and the free margins  covered with  thin lead or adhesive
plaster.   Folds of linen, wet with water, are placed upon the limb under-
neath the splint, and the whole apparatus is kept in position by rollers or
tapes.  This apparatus is said to be light, cool, cheap, and  permits  the
application of lotions  without disturbing  the bandages.   Large  quan-
tities of it have been  ordered for  the use of such as may require it in
the war now raging between England and Russia. 
                        AMERICAN APPENDIX.                     889

   The felt splint forms, likewise, a very admirable apparatus.   Professor
Hamilton of Buffalo regards tho splints made of this material, as " the best
ever used," and in a communication to the  Buffalo Medical Journal, for
December, 1853, he has given the recipe for making them.   It is as fol-
lows.  " Dissolve three pounds of gum shellac in two quarts of alcohol.
It should be dissolved in a  tin vessel, furnished with a  tight cover  to
prevent evaporation.  Spread a piece of old  or new woolen cloth on a
board, and with a clean brush saturate both sides of the cloth with the
solution.  Hang it up until it is thoroughly  dried.  Lay it  again upon
the board and apply a second coat of the  solution to one  side only of
the cloth.  Dry again, and apply a third coat to the same  side.  There
will now be three successive layers upon one side, and one on the opposite.
While the last  coat  is yet  fresh, fold the cloth so that the side having
three coats shall be applied to itself.   Now, with a hot flat-iron, smooth
and press the surfaces together.  When it  is cold, a slight  rubbing with
sand paper makes it fit for use.
   It becomes a firm, almost unyielding board, but exposure to a moderate
heat will make it pliant, so that it can easily and  accurately be adapt-
ed to any surface."
   Certain cases of fracture now and then occur in which we are compell-
ed to adapt our treatment to the peculiarities which they present.

                      Fracture of the Clavicle.

   The apparatus introduced by Dr. George Fox into the  practice of the
Pennsylvania Hospital, in 1828, is acknowledged, we believe, to be the
best yet devised for the treatment of fractures of the clavicle.  It consists
of a stuffed collar ;  a pad about five inches  long, four wide, and two or
three inches thick at the base ;  and of an  elbow piece or sling, as  rep-
resented in Figs. 1, 2, 3,

                               Fig. l.
Fig. 3.
  The collar is formed of a piece of muslin four inches wide, and long
enough to pass around the shoulder.   It is sewed together on its sides,
then stuffed with cotton, and joined at its ends.  The pad is wedge-shaped,
neither so thick nor so long as Desault's, as it is intended to fill merely
the space between the upper part of  the arm, and the side of the body,
  vol. in.                     112
\ 
 890             NEW  ELEMENTS OF OPERATIVE SURGERY.

 and yet leave a space  between the  elbow and the  ribs.  The thick end
 of the pad is attached  to the collar by two tapes.  The elbow piece, or
 sling, is made of  strong muslin or brown holland, and resembles half of
 the sleeve of a coat.  It embraces the elbow, mounts half way up the arm
 and descends nearly to the wrist.   Two  pieces of broad tape are attach-
 ed to its upper and posterior ends, of sufficient length to extend across
 the back to the collar.   Two loops are attached to its lower portion, for
 the purpose of receiving a tape for the front fastening.
  The collar is placed on  the sound shoulder; the pad in the  injured
 axilla where it is  fixed by carrying the tapes, one in front, the other be-
 hind the chest, which are then tied to  the collar.  The  fore-arm is then
 to be flexed ; and the sling or elbow-piece, is  to be fastened to it  and the
 arm.  The latter  is brought  against the pad by carrying the fore-arm
 across the chest, and the loops  near the wrist, on the sling, are  tied to
 tho  front of the collar.
  We find in the  New-York Journal  of Medicine for March, 1855, the
 following engraving and  description of  a modification  of Fox's appara-
tus by Dr. Bartlett, which may be procured from the well known surgical
instrument manufacturer, Mr Tieman,  63 Chatham  St.,  N. Y.
  For an  axilla pad, roll a strip of woolen flannel, 4 or 5 inches wide
around the axilla strap, to the size required.   Put on  the collar.  Ap-
ply the pad, and pass the strap under the collar, thus securing each in its
place.   The sling, being first attached to the collar by the forward strap
is made to receive the arm of the side affected, when  the  straps at the
back of the sling should be buckled, one  behind, the other forward, to
the ends of the collar, with the requisite tightness to reduce the fracture
and maintain the ends in apposition.
  The apparatus may be used for either side, by changing the attachment
of the sling, as will be readily perceived.  It may also be used for dislo-
cation ot the clavicle, fracture of the acromion process, and neck of the
scapula.

                    Fracture of the Humerus.

  In some cases the common splint, or starched  bandage is insufficient
to keep up permanent  extension and counter-extensionfwhenwe  may
resort to an instrument like  that represented in the  following figure; 
AMERICAN APPENDIX.
891
taken from Mr. Grantham's Facts and Observations in Medicine and Sur-
gery, p. 4.
                               Fig. l.
  Mr. Lonsdale has invented a splint for the same purposes.  " It consists
of a thin bar of iron, about an inch and a half wide, and long enough to
extend from the axilla to the elbow, marked B, in the wood-cut, Fig. 2.
  The lower  end of the  bar  curves upwards  under-      Fig. 2.
neath the elbow, so as to allow of  this part of the limb
fitting into it at C.  This  curve  terminates in a hook
E, for the  attachment of a bandage; and on  the splint
opposite  to this  hook is a  small bar, placed  across
the perpendicular, also  for the attachment  of a ban-
dage.  To the  upper extremity of the splint a crutch
is adapted, A, which fits  underneath  the axilla, and
is movable up and down, being confined  at pleasure
by means  of a small screw, placed  at the side of the
vertical bar."  The crutch-like  extremity is secured
in the axilla, the upper  part of  the arm fitting into
it.   The  inferior  curve is fastened to the elbow with
a bandage, which is also attached to the splint at the
hook, and at  the transverse  bar.   The whole limb
is then to be  enveloped  in a roller, and one or two
lath  splints applied on the exterior, or  anterior sur-
face of the limb, while the fore-arm is to be supported
in a sling.
   In cases of compound fracture  of the  condyles, or their vicinity, the
following splint contrived by Mr.  Mayo, may be found of great service.
   It consists of two splints joined together by two small bars, so as to
leave a space between them for the elbow to fit into.  One of the  splints
B, is made for the  back  part of the arm, while the other C, is for the
fore-arm,  and D  for the  hand.  The  elbow resting in the intervening
space A,  all pressure upon the joint is obviated.
 
892            NEW ELEMENTS OF OPERATIVE SURGERY.


                               Fig. 3.
Fractures of the Radius.
  The method recommended by Dr. Bond, of Philadelphia in the treat-
ment of fractures of the lower end of the radius, is doubtless the most
simple and satisfactory of all the various plans hitherto proposed.
  The following are his directions for preparing the dressing and its
application.
  1. With a light board of proper thickness for a splint, take a profile
of the  well forearm and hand of the patient,  placing the  hand in its
habitual inclination towards the ulnar side of the arm, and extend the
profile from the elbow downwards, so that  it  shall  reach the second
joint of the fingers on the inside, when these are moderately flexed—as
much flexed as they are when the  points of the thumb  and  fingers are
brought into contact.   The lower  end of the board must be cut off
obliquely  (at  an angle of fifteen  or eighteen degrees) in a direction
corresponding with that of a body  grasped in the hand, when the hand
is inclined to the ulna, as below indicated in Fig. 1.
                               Fig. l.
  1. A board  cut  to  correspond  with the profile of the forearm and
hand.
  Fig.  2. A.  This whole  space  down to the  palmar block (B)  to be
covered with pasteboard.  C. C. Parts of the block, which must be more
or less  cut away, to suit the prominences of the hand.  D D. The pro-
jecting and elevated edges of the  pasteboard.
  " 2. Cover the board thus  prepared with sheeting, or other strong 
AMERICAN APPENDIX.                    893
fabric.  This may be done by winding around it from end to end a narrow
rolling bandage, covering all of it as nearly as may be with  few  or no
duplications.  This is the most expeditious method.  A neater one is to
cut a piece of sheeting of the general form of the board, but extending
beyond the board on every side, and fastening it upon the board  either
by  a few stitches, drawing towards each  other the overlapping edges,
or gluing down those edges upon  that side of the board  which is to
be towards the arm, and which edges are to be covered with the  paste-
board.
  3. Prepare a block of soft, light wood, from seven-eighths to eleven-
eighths of an inch thick, and from  two to two  and a half inches  wide,
according to  the size of the patient's  hand, and of a length correspond-
ing with the  width of the board in the palm of the hand.   This  block
is to be carved and rounded, so as to adapt it to the  form of the  hand,
and make it easy for the thumb, and in the grasp of the hand when  it is
placed on the board.   It is to be fastened  there by screws or nails, so
that the remote edge of it shall correspond exactly with the lower oblique
end of the board.
  4. Upon that part of the board not covered by the palm-block, fasten,
by  means of small  carpet-tacks, a piece  of book-binders'  pasteboard,
extending on each side beyond the edges  of the board  about an inch.
If the pasteboard be very thick and stiff, make a slight incision in it along
the edge of the  board, in order to bend more easily the two projecting
portions of it, thereby making a kind of box for the lodgment of the arm,
as represented in Fig. 2.
  This splint maintains such an inclination of the hand upon  the  fore-
arm as shall most effectually relieve the muscles from tension, or put them
in a state of repose.   The  hand and fingers are, likewise, retained in
such a position  that, if rigidity should result, the  member  shall be as
little an incumbrance, and retains as many of its uses as possible.   It is
easy of application,  requiring no extraordinary skill,  and is  but  little
liable to become deranged.  It is  comfortable to the  patient, and  is at
the same time effectual."   (Amer.  Journ. Med. Sciences, April, 1852.)
Professor Fenger, of Copenhagen, is said to have been very successful
in the treatment of this fracture, by keeping his patients in the recum-
bent position, with the injured member resting on a plane which is in-
clined upwards  from the  elbow to the wrist, whilst the hand is allowed
to drop over the most elevated part of this plane, the arm being only so
far confined  as to prevent its  being shifted from its position—an unne-
cessary precaution if the patient will keep entirely at rest.  (Brit.  For.
Med. Chir. Rev. April 1849, p. 405.)

                       Fracture of the Femur.

   Most British  and  American surgeons adopt  the  straight position of
the lower extremity in the  treatment of fractures of the  femur, and
in  this country the preference seems to be given to Dr. Physick's modi-
fication of Desault's apparatus.  In fractures of the upper  third of the
thigh, however, where the lower end of the upper fragment is tilted up
by the contraction  of the iliacus internus and psoas magnus muscles, it
is impossible by this means to retain the ends of the fragments in coap- 
894            NEW ELEMENTS OF OPERATIVE SURGERY.
tation, and we are obliged to resort to the double inclined plane.  Pro-
fessor Nathan R. Smith, of Baltimore, has devised a very light and por-
table instrument which  seems admirably  adapted to this purpose.   It
allows suspension of the limb, and a gentle swinging motion.  Fig. 1. is
intended to represent this instrument.

                                Fig. l.
  When a straight  splint is required, nothing can exceed in simplicity
that so long employed by Mr. Liston.  It consists  of a single  piece  of
deal-board, long enough to  extend from a point opposite the nipple, to
three or four inches beyond the  foot.  Its  lower extremity is notched,
and in its upper, two holes  are bored.  The lower end  is perforated so
as to adapt itself to the  malleolus.   The splint is covered on its inner
face by a cushion, and the leg bandaged from the toes nearly to the seat
of fracture,  before the former is  applied.   The fracture  having been re-
duced, the perineal  band is tied  at the upper end of the splint, and a
roller applied so as to secure the whole limb and side of the body to the
splint.
                               Fig. 2.
  Mr. Fergusson states that he has used this for the  last twenty years,
and has no hesitation in giving it the preference.  (Pract. Sursrery, 3d
Lond. ed. p. 413.)                               V
  In a communication to the Phil.  Med. Exam,  for July, 1849, Profes-
sor Miitter has given a description of a modification of the straight splint
which was found very useful by Dr. A. Hays, during  the  war  of 1812,
in cases of compound fracture caused by gun-shot wounds.  Mr.  Erich-
sen states that he has used in compound fractures, where the  aperture
exists in the posterior and outer part of the limb, an instrument construct-
ed on the same principle.  It is brackctted opposite  the seat of  injury,
as shown in Fig. 3. 
AMERICAN APPENDIX.
895
  Dr. Jas. L. Van Ingen, of Schenectady, employs the following novel
method in the treatment of fractures of the lower extremity, the results
of which have proved  very satisfactory in his practice.  He regards it
as superior to all other plans of  treatment on account of its " simplicity,
ever-readiness and comfort to the patient."   Its novelty consists in mak-
ing counter extension at the inferior extremity of the limb, extension and
coaptation being effected by the natural relaxation of the muscles during
sleep, and tho weight of the body.
  We have recently been  personally assured by Dr. Van  Ingen, that he
has tried this method in numerous cases, and that it prevented the oedema
of the limb generally accompanying the use of apparatus which leaves
the limb in a more  depending position, and that union has  been  more
speedy in consequence  of  the little irritation or pain  which the patient
is compelled to suffer.  It is in fact as he calls it, "a natural extension."

                                Plate. 1
  a, b, c, d, e.  Bricks or blocks to elevate the foot of the bed as much as required.
 /. A half gaiter and straps tied to
  g.  A slat, or narrow piece of board, nailed to or screwed to the bed posts.
  i. A small hair, husk or straw pi'lcw, not touching the heel but supporting the concavity of
the leg and ankle. 
896              NEW  ELEMENTS OF OPERATIVE SURGERY
Plate 2.
  a, b, c, as plate 1.
  d, d.  Gaiter and straps.
  e.  Pillow.
 /. /. /•  Splints of coaptation for a broken tibia, fibula, or both, sewed in a splint cloth, and
to be covered by a "Scultetus' bandage,"  and which can be adjusted each  day without dis-
turbing the limb.
  g, g.  The same for fractured thigh.
Plate 3 the same as plate 1.
■^H-stumr. £ac:h.x,
  i, i. A slip of adhesive plaster confined by a small " Scultetus " and being substituted at
pleasure  for the gaiter or moccasin of (/) in plate 1, and slit at the ends to pass around the
slat at the end of the bed.
                         Fracture of the Patella.

  M. Malgaigne has devised an instrument, by which, in cases of fracture
of the patella, the fragments can be at once approximated and retained
in coaptation.   It consists of two double  hooks, one of which is fixed
above the  upper  fragment, the  other below the  lower fragment.  Tho
points are  thrust through  the skin directly down to the bone, and  by 
                        AMERICAN APPENDIX.                    897

means of a screw, the fragments may be brought  into perfect  contact.
Fig. 1. represents this apparatus.

                               Fig. l.
  Mr. Lonsdale recommends an instrument consisting of a splint  upon
which the limb reposes, and to which a foot-piece is attached in such a
way as to be movable up and down to accommodate the  splint to limbs
of different lengths ; to  the under surface of this splint two vertical
iron bars are connected, A B Fig 2, at about its centre, each supporting
a horizontal arm bent at right angles, G G : these horizontal pieces slide
upon  the upright staffs, but can be arrested at any point by the screws,

                               Fig. 2.
 C D;  from these arms, depend  other  vertical rods,  movable  upon the
 former, and like them, fixable by similar screws, E ; finally, to the lower
 end of each of these second  perpendicular rods, an iron plate, F F, of
 a horse-shoe form, is  attached, by means of a hinge-joint.   The  splint
 is to be well padded, and the foot and  leg secured to it by a roller, these
 parts having been first covered with a bandage.  The  fragments are then
.to be brought in contact, and the muscles relaxed after which the upper
 horse-shoe plate is applied  above  the upper fragment, a soft pad inter-
 vening, and the other plate  is placed just below the  inferior fragment.
 The plates are then secured by means  of the screws, and a roller passed
 around the thigh and upper part of the splint.
   The advantages claimed by Mr. Lonsdale, for this instrument, are, that
 it  produces no constriction  of the  limb, leaves the  injured  part ex-
 posed, and admits the application of anti-phlogistic remedies.  It certain-
 ly must  be less painful  than  that of   M. Malgaigne,  although  we have
 known patients bear the latter with but very trifling inconvenience.
   Dr. Neill of Philadelphia employs straps of adhesive plaster 1\ inches
 wide,  for the  purpose of bringing together the fragments of a fractured
 patella.  These straps are carried around the lower third of the thigh, so as
 to press the muscles and the detached fragment of bone towards the knee,
 and then by bringing it  across the popliteal  space, it passes round  the
 leg, immediately  below the  inferior edge  of  the  patella.   Four or five
 of these  straps are  applied, overlapping  each other, until the coils of
 plaster above the  knee extend down to the  edge of the patella.   In con-
   Vol.  III.                   H3 
898           NEW ELEMENTS OF OPERATIVE SURGERY.
junction with this method, the ordinary means of keeping the limb extend-
ed may be employed (Phil. Med. Exam. Jan. 1854.)

                       Fracture of The  Leg.

  The starched bandage, as we have already stated, is not very exten-
sively used in this country in the treatment of fractures of the lower ex-
tremity.  We have  frequently employed it, and have been much pleased
with its  effects.   But cases now and then occur, in which it is difficult
if not  impossible, to fulfil  with it  every indication, and  we are com-
pelled to resort to other means of  effecting  extension and maintaining
the fractured ends of the bone in coaptation.
  A very simple and ingenious method has been proposed by Dr. Cros-
by, of New-Hampshire, an account of which, with illustrations, was pub-
lished in  the American Journal of Medical Sciences for January, 1854.
We insert Dr. C's description, and  the cuts.

                              Fig. l.
  Fig. 1 represents the application of strips of adhesive plaster to the
legs by which we attach the limb, in case of fractured  thigh, to what-
ever instrument is used for permanent extension.  1 1, represents strips
of cotton cambric spread with common adhesive  plaster, to be applied
one on each side of the leg, long enough to extend from above the knee
to the ankle, the ends from the ankle hanging loose below the foot seve-
ral inches, unspread, to be tied to the instrument  by which extension is
made.   These strips  should be from two to five inches wide, according
to the size of the limb, and should be recently spread.   The leg should
be shaved before the plasters  are  applied.  2 2, represents a roller ap-
plied from the toes to the knee, to confine the adhesive strips to the leg,
and prevent swelling.                                             °
  This is the method of applying the extending force, which I used, for
the first  time, in 1849, and which I have  reason to believe had never
been suggested to the profession in a manner to attract the attention of
surgeons, until it appeared  in Prof.  Mussey's  Surgical Report to the
American Medical Association, at their session in  Cincinnati, in 1850.
  Vy this method, any necessary amount of force may be applied, for the
purposes of  setting the bone and keeping the limb sufficiently extended,
without pain or inconvenience to the patient. 
AMERICAN APPENDIX.
899
  Having found this method of extension so satisfactory to myself in the
management of several  cases  of fracture of the thigh,  and from  the
opinions expressed to me of its  superiority over all other methods by
Professors  Mussey, Parker, Kimball, and  Crosby, and also  by the dis-
tinguished surgeons of the Massachusetts General Hospital, where it was
early introduced, I was induced to try it in fractures between the knee
and the ankle, to produce both  extension and counter-extension in all in-
juries requiring such extension.
  Fig. 2 represents  Goodwin's splint, 1 with the addition of the irons,
e e, screwed to the edges of the  base of the splint, four or five inches
above the knee-joint; a  a are strips of adhesive plaster  applied one to
each side of the ankle, higher or lower, according to the location of the
fracture ; b b, adhesive strips running from below the knee upwards, to
be passed round the irons e e, and pinned below them ;  c, strips to be
passed round the foot and ankle,  to keep the longitudinal strips firmly
attached, and to prevent  swelling ; d, strips to pass round the leg below
the knee, to fasten the longitudinal strips.  The circular strips  may be
spread  with adhesive matter,  or not, as may suit the  surgeon.   I have
generally used them spread, as  being more certain to hold the extending
strips.
                                Fig. 2.
   My method of dressing a fractured leg below the knee, requiring ex-
tension, is in the first place to shave the leg, and then apply fresh-spread
adhesive plaster, as represented by the plate, then to place on the splint
a cushion of some  sort, extending from a little below the foot to the
knee ; on this lay a piece of oiled silk, to keep the cushion from becom-
ing wet; on this place a many-tailed bandage, in strips ; having made
these preliminary arrangements, and screwed the foot-board as high up
as possible, assistants should raise the leg so high that the  splint,  with
all its appendages,  can be placed under the limb, letting the foot rest
against the foot-board ; the foot is now to be made fast to the extending
apparatus by tying the floating  ends of the longitudinal strips to the foot-
board.  The assistant is now to extend the limb upwards on the  splint,
as far as he can  easily, and hold it while the surgeon pins the loose  ends
of the adhesive  strips, above the knee, around  the irons e e.
   The whole thing is now completely under the control of the surgeon ; ^
he can extend the limb by turning the screws until it is at its full length.
This  may be  accomplished at*nce, or he may be several days in doing
it.  When the limb is extended  as much as is desirable for the first dress-
in o-, one course of the many-tailed bandage should be folded over it, and 
900
NEW ELEMENTS OF OPERATIVE SURGERY.
kept wet with cold water.   The limb  should be treated in this way for
several days, until the inflammation and swelling have somewhat abated,
daily making  extension until the  limb is at its  proper length.   When
these objects  are accomplished, as early as the tenth or twelfth day, if
the extension  alone be not sufficient to  maintain perfect apposition, after
applying one  course  of the many-tailed bandage, as before directed,
binder's-board splints may be applied, and secured by the other folds of
the bandage.
  The  advantages of  these  dressings  are, that the surgeon can se* the
leg with much les difficulty to himself, and  with much  less pain to the
patient; that extension can be  more  perfectly maintained;  that in
the inflammatory  stage he can dress the limb much more loosely, and can
apply his evaporating lotions with better effect;  and if the fracture  be a
compound  one, requiring to be dressed  daily,  it can be done with less
danger  of deranging the fracture.
  It has been  objected to this method of dressing, that the adhesive plas-
ter will irritate the skin, so that the patient cannot bear it.   There  may
be occasionally a  case  of this sort, but they must be very rare ; I have
never seen  one.   In a  case  of compound comminuted fracture of  both
bones of the leg,  not more than two inches above the ankle-joint, I  kept
these dressings applied without change,  and without irritation, sixty days,
and got a sound leg, and of  proper  length, after the removal of several
pieces of bone."
  In 1849, Professor Hamilton, of Buffalo, published his Fracture Tables,
comprising  at that time 136 cases.  The object of these Tables was to
show  what  might generally be expected in the  way of a perfect cure.
In 1853, a  Supplement was added, making a collection of 461  cases.
These are furnished by his own  private  and hospital practice, and by the
hospitals of this city.   They have been drawn up with great care, and
show that of this  whole number, perfect cure  was effected in rather less
than one-half of the cases.  They were all treated by regular practition-
ers, and by surgeons  of respectable  standing.   Professor H. in every
case carefully examined and measured  the limbs himself, and always in
the presence of other medical men.
  In  connection  with  this  subject we must not omit to notice the  new
method  of treating ununited fractures  proposed by Professor Brainard,
of Rush Medical  College, Illinois.   His Essay received the prize of the
American Medical Association, for 1854.  The same treatment  he re-
commends for  the remedying certain  deformities arising from anchylo-
sis, &c.  The  object of his investigations, as stated by the author, was:
1st. To establish, by experiment,  the  principles upon  which the treat-
ment of ununited  fractures should be conducted  ; and to show that these
principles are  applicable to  the human  subject.   2d.  To propose  a  new
method  of treatment of certain deformities which  result from true an-
chylosis,—union of fractures in an angular position, rachitic  curvature,
etc.   It is divided into three parts :—1. Experimental researches  on the
effects of foreign bodies, when allowed to  remain in contact with the osse-
ous tissue, and on certain wounds of the bones.  2. Treatment of un-
united fractures by subcutaneous perfection of bone.   Cases treated in
this manner.
  3. Treatment of deformities of the bones by subcutaneous perforation.
Experiments on this subject. 
                        AMERICAN APPENDIX.                     901

   The following are Prof. Brainard's conclusions as to the effect of for-
eign bodies when allowed to remain in contact with bone:—
   1. Foreign bodies, of every kind, placed, or allowed to remain in con-
tact with any part of a bone, in a manner to keep up suppuration, pro-
duce absorption of it, and have  no tendency whatever to give rise to the
production of callus.  The use of setons, pegs, wires, and foreign bodies
of every description, as a means of promoting the  formation of callus,
is a practice not founded on correct principles, and is often  dangerous.
The seton is more  properly employed for the purpose of  dividing a bone,
or keeping up a false articulation, than for uniting it.
   2.  Sequestra and foreign bodies, imbedded in bone, may be brought
to the surface when, by perforation or otherwise, instruments or ligatures
can be so attached to them as to draw them permanently, with but mod-
erate degree of force, in that direction.   As soon as they press against
the living bone, they cause its absorption in the direction toward which
they are drawn.
   3.  That power of absorption  of bony  tissue attributed to  the perios-
teum and the medullary membrane, exists also in the substance of the
bone itself, as is proved by the insertion of pegs into perforations  of
bone, absorption taking place around them, not only at  the surfaces, but
at all the intervening points.
   Having ascertained that the effects of foreign bodies were to produce
absorption of callus when  placed in contact  with it, he thus  announces
his views of the indications of treatment in cases of ununited fractures.
   The object to be desired in these cases is, as  it appears to me, the
production, by subcutaneous wound, of fresh osseous surfaces opposite
to and in contact with each other, with such division of the soft parts as
will excite  a moderate  inflammation, without  suppuration, around  the
in false joint; and a wound of the bones, of considerable depth and size,
capable of producing that vascularity and softening always noticed fractur-
ed extremities of bones, before union takes place.   These fresh surfaces,
in some cases, require to be numerous, and equal in the aggregate to those
produced by resection ; and the  operation by which they are made should
be repeated from  time to time.   Hence, it must be an  operation which
does not expose to violent inflammation, or give great pain.   It should,
moreover, be one capable of being  employed in connection  with  other
methods, recognized as useful or necessary to preserve  immobility.
  Prof. B.  has invented a perforator capable of penetrating the hardest
bone or ivory with  facility in any direction.
  The following is an illustration of this instrument.
»
  The handle is so constructed that points of different sizes may be insert-
ed as occasion requires.   The following figure represents its application.
  In most of the cases, he says, it is better to commence with not more
than two or three perforations, in order that the  effect  produced be not
too severe.  But one puncture is made through the skin.  On withdraw-
ino* the instrument, collodion is to be placed upon the point of puncture. 
902
NEW ELEMENTS OF OPERATIVE SURGERY.
  In case of fracture where the  extremities are differently situated, it
must be applied in a different manner, and in such away as to effect the ob-
ject proposed, viz.  : profound as well as superficial wounds of the extrem-
ity of the fragments ; and a division of the tissue which is seated between
them.   *  *  *  Each  of the  different  parts of the  operation  which
we have described, is essential to its success.   The division of the tissue
situated between the fragments, would, of  itself, have but little effect;
combined with scratching their  extremities, its effect  is not great, as
we have demonstrated by experiment; but when accompanied by wounds
of the bone, there is a very permanent and  efficient action produced,
which puts the extremities in a condition to join the soft parts, in  effect-
ing union.  This can be rendered greater, by increasing the number of
punctures, or using an instrument of large size.  The operation is to be
followed by the application of suitable splints, or apparatus for the pur-
pose of securing immobility.   It should be repeated  from time to time,
and carried to a greater  or less extent, as the effects produced may in-
dicate.
  At the time of the publication of his Essay ( Trans. Amer. Med. Assoc.
vol. vii. 1854.) Prof.  Brainard  could adduce but seven cases in which
his plan had been  successfully adopted.   Two of these  occurred in the
practice of Prof. Mussey, of Cincinnati, and  two in that of Dr. Jewett,
of Canandaigua, N. Y.   The results of subsequent trials will be watch-
ed with much interest, as the  views of Professor B.  differ so materially
from  those on which, until within a recent  period, surgeons have based
their treatment.  We have neither time nor space to discuss the aue3tion
of priority which has arisen in connection with this subject.
                            HARELIP.

  Mr. Henry Smith, of London, has  published  a paper in the  London
Medical  Times and Gazette, for  March, 1854, in  which he  advocates
the practice of operating at the earliest period in certain cases of hare-
lip.  By  removing the deformity  we  place the child in a much more fa- 
AMERICAN APPENDIX.
903
vorable condition to receive nourishment from its mother's breast, while
the mother and friends are relieved from the annoyance which they must
otherwise experience.  Another argument in favor of an early operation,
is, that there will be a much less chance of subsequent deformity in the
part, as in the first  period of life, the lip, together with the other struc-
tures  of the body become more  fully and rapidly developed.  But it is
in those instances where the harelip is complicated with a more or less
extensive fissure in the palate, that he  would particularly urge an early
operation, as the approximation of the edges of the lip exerts the most
favorable influence  upon the fissure  in the hard  palate.   The bones at
this tender age are  so soft  and compressible, that after  the  operation,
the fissure becomes either  entirely  closed or diminished in size to one
third or one fourth of its original extent.  He  refers to a case, in which
Mr. Bateman, of Islington, operated only four hours after birth.  The
fissure in the palate was sufficiently wide to admit the mother's  thumb,
but it became, after the close of the lip,  so contracted  that it  would
scarcely admit the edge of a sheet of writing paper.
   Mr.  Smith, has himself operated upon an infant  six days old. We
have long believed in the advantages to be derived  from an early  opera-
tion, and have repeatedly performed  it  at the end of the third week.
                             HERNIA.

  We believe that it is generally conceded  that  one of the  greatest
provements made in the operation, particularly of femoral hernia, is that
recommended by Mr.  Gay, in his work on Femoral Hernia.  By making
a very limited incision on one  side of the  neck of  the  tumor, the  stric-
ture may generally be divided without opening the sac ; the whole pro-
ceeding, according to this method, being little more than the taxis, with
the addition of a superficial incision.  The  incision being  made, Mr.
Gay dissects through the superficial structures until the sharp inner edge
of the falciform process is exposed ; under this a flat director is pushed,
along which the hernia knife is carried, and the stricture divided, for a
line or two,  upwards  and inwards.   The reduction may then  often be
effected ; should any obstacle be encountered, the neck of the sac  must
be  well drawn down  and exposed, and any transverse  bands  situated
upon  it dissected through with the  scalpel and forceps.  Mr.  Erichsen
remarks that he has most generally found this necessary  before reduction
could be accomplished.   By this simple procedure the  dangers of the
operation are greatly diminished, but if the tumor be of much magnitude,
more extensive incisions will be required.
  During the operation for strangulated hernia, an accident  sometimes
happens, productive of the most disastrous consequences to the patient,
if it be not  timely discovered and relieved.  We allude to the reduction
of the tumor with its contents still  strangulated by the  sac.   Cases  of
this kind have been  reported by Saviard, Arnaud, Richter, Sabatier, Sir
Astley Cooper and Mr. Key, M. Demcaux  and others, showing that the
most eminent surgeons have been guilty of supposing that they had pen-
etrated the  true sac, when the  intestine was still covered by the perito- 
904
NEW ELEMENTS OF OPERATIVE SURGERY.
neum.   In a paper which was first published in the American Journal of
Medical Sciences, October, 1846, and afterwards in an enlarged form, in
the New-York Journal of Medicine for November, 1850, and January,
1851, we have  endeavoured to embody all the  facts bearing upon this
subject, which had been recorded up to that time.   Since that period, a
number of the same  kind have been published.  The following is a re-
sume of those contained in our essay.

                      Reduction by the Taxis.

  We have thus collected (including our own supposed case) 46 exam-
ples of the reduction in mass which followed the application of the taxis.
In the report of M. Homolle's case, mention is made of his having met
with 2 other  cases " under similar  circumstances," which  would make
our whole number 48,  though we are unable to learn  whether  these
other cases of M. Homolle were reduced by the taxis, or whether they
occurred during  the operation.   Of these, 36 were ingunial, 4 femoral,
2 ventral, and in 6 cases the situation is not mentioned.
  Age.—In 19 only is the patient's  age recorded, and in these it was as
follows :—50, 40, 18, 13, 40, 55, 47, 68, 50, 30, 40, 42, 75,  30, 55, 59,
61, 75, 79.
  Duration of  Hernia.—In eighteen cases, it is said  to  have  been of
" many years ;" in 3, " several years ;" and 1 was described as being an
" old one ;" 1, congenital: and the  rest as follows.  12, 11, 54, 20, 30,
20,^30, 5, 12, 30, 40 years.
  Sex.—In 27 cases in which this is noticed, all  but 4 were males.
  Size of Hernia.—In 20 cases where  it is mentioned, 8 were " large ;"
5, size of " hen's egg;" 1, " turkey's egg:" 1, " pigeon's egg ;" 2, " large
walnut;" 1, " good-sized pear;" 1, half the size of " one's fist;" 1, " not
small; " 2, " small;" 1, " scrotal."
  Facility of Reduction.—Of 26 cases in which  the circumstances con-
nected with the reduction are recorded,  13 are said to have been returned
easily, quickly, " without difficulty," by the patient; whilst in 14 it was
only effected  " after some attempts," "  after many attempts," " with dif-
ficulty," and  after the use of " the warm bath and bleeding."
  Result of  Operation.—20 cases were subjected to operation, of which
11 recovered, 1 is supposed to have  recovered, whilst 6 died from  peri-
tonitis, effusion of fecal matter, from gangrene, and in 2 cases the stricture
was found undivided.
  Spontaneous  Cure.—This occurred in 1 case only.
  Reduction  of sac during  Operation.—Under this head my collection
embraces but 9 cases, 7 femoral  and  2 inguinal.  Velpeau, it will  be
remembered, states, that he has become acquainted with 15 cases of this
kind, but we give the number only of those which we ourselves have been
enabled to collect.
  Result.—5 proved fatal, 3 recovered, and 1 not stated
  Spontaneous  Reduction.—Variety, crural; age 61; duration 28 years  :
size of  hen s egg ; operation successful.
  As will be seen, the above synopsis refers to cases in which the  acci-
dent occurred during the application of the taxis, as well as the opera-
tion.   Ihe  treatment required, in the  instances where  the hernial sac 
AMERICAN APPENDIX.
905
and its contents have been reduced, is obvious, viz.:—the tumor must be
made to reappear, and the operation performed as if no reduction  had
been effected.
  The propriety of operating in strangulated hernia without opening the
sac, has of late been much discussed by British Surgeons.   Among the
warmest advocates of this practice, is Mr. Luke of the London Hospital,
an institution where more cases of strangulated hernia are admitted than
at any other in that metropolis.  In the  31st  volume  of the Medico-
Chirurgical Transactions, Mr. L. states that he has operated in 84  cas-
es of hernia ; in 25 the sac was opened, but in 59 it was unopened.  Of
the former 8  died; whilst of the  latter only 8 died.  Of 77  operations
reported by Sir Astley Cooper, 36 proved fatal, and according to the sta-
tistics of Dr. Turner, embracing 545 cases collected from various sources,
260 died.   Of 31  cases of femoral hernia operated on by Mr Luke, in 7
only was it necessary to open the sac.
  It is stated that even if the  surgeon fail in completing the operation
in consequence of  adhesions or constriction of the sac, no  harm can re-
sult, for the sac, after being exposed, may be opened in the ordinary way,
and the stricture  divided from within.   Mr. Hancock, of the Charing
Cross Hospital, has opposed  this operation, and  really, after examining
the facts collected in  our paper on  the reduction in mass to which we
have referred, it seems to us, that the  cases in  which it is said no harm
can be done,  are just those, in which the  accident under  consideration
is likely to occur.  Mr. Liston regarded it as  peculiarly liable to this
objection.   (Practical  Surgery, 2d Lond. Ed.)
  By the sloughing  of the intestine in strangulated hernia an artificial
anus is formed, but it is seldom an operation has been attempted to reme-
dy that occurring  in crural hernia.
  To Dr. J. Mason Warren, we  believe, belongs  the  credit of having
first undertaken this in the United States.   His operation was performed
in 1847.  He employed an instrument  which  he considers vastly supe-
rior to that of Dupuytren.  It resembled an old-fashioned polypus  for-
ceps, with  the branches detached, and united by a movable pivot, instead
of a fixed joint; the handles were perforated with a screw vice, and the
jaws serrated throughout.  It is less clumsy, causes more complete stran-
gulation, and is far more speedy in its operation  than the instrument used
by Dupuytren.   His enterotome generally separated about the seventh
or eighth day ; whilst that employed by Dr. Warren came  away on the
third, yet  no effusion or other evil  consequence  resulted, although the
condition  of  the patient was  very unfavorable for the formation of plas-
tic lymph.   For further details of this interesting case we must refer to
the American Journal of Medical Sciences, July, 1848.

               Cough-impulse as a Symptom of Hernia.

   We copy from a recent number of the London Medical Times and
 Gazette,  the following remarks on  this subject:
   Several  instances have recently come under our notice, illustrating the
value of the  knowledge of the  fact,  that in tightly strangulated hernia
no cough-impulse  is ever felt.  In all the reducible or merely incarcerat-
ed  forms,  the  information derived  by making  the  patient cough is so
   vol. in.                     114 
 906            NEW ELEMENTS OF  OPERATIVE SURGERY.

conclusive, that it is not surprising that attempts should be made to ap-
ply the same test to cases in which strangulation exists.   Entire forget-
fulncss of the condition of  the bowel could, however, alone  induce  any
expectation that impulses generated within the abdomen  would be com-
municated to it.   In all cases in which the  constitutional symptoms  of
strangulation are present, the diagnosis as to whether the tumor be her-
nial or otherwise, must be made without reference to its movements dur-
ing coughing.   Much valuable knowledge on other points may, however,
be yet derived from the test,  If—in the  certainty from other signs that
the tumor is really a hernia—there be not the least  impulse,  a fair  in-
ference may be drawn that  the stricture  is tight.  If impulse be felt in
the upper part of the neck of the  tumor, and not in other parts, the seat
of stricture may  be accurately determined,  being, that is to  say, just
below the spot where the perception  of impulse  is lost.   On this latter
point Mr. Luke has, in his paper  " On the  Operation for Strangulated
Hernia," Medical  Gazette,  1839—40, insisted strongly;  indeed,  we
believe he was one of the first to direct attention to its value.
  With regard to the absence of  cough-impulse  in strangulated hernia,
generally, our  surgical manuals have, for the most  part, neglected to
make any observation respecting it, while in some, from the terms used,
it might  be inferred that it was an ordinary symptom.  It is still not
infrequent to see cases reported in which its absence is noted as having
been a source of difficulty and doubt.  Most deeply would it be deplored
should such absence ever lead to delay in  performing the operation, since
it is, in fact, a conclusive indication of its necessity.  We have not made
the statement  printed in  italics above without first instituting much in-
quiry among those^of most experience, and  also availing ourselves of
every opportunity which has of late occurred for acquiring data in respect
to it.  The following sentence in its support we quote from a note by
Mr. South, in his edition of Chelius :—" I  have on more than one occasion
heard surgeons of eminence speak of dilatation of a strangulated rupture
on coughing, which, I must confess, I think impossible if the rupture be
more than  incarcerated."

                     Hernia Radical, Cure of.

  At a meeting of the Academy of Medicine,  March,   28th, 1854, M.
Jobert presented a patient  who had been cured by the iodine  injection,
both of hydrocele.and a congenital hernia  with which it was complicated.
M.  Jobert stated  that this  was the third  or fourth instance in which a
similar result had followed in  his hands, the  same mode of treatment.
The discussion of this mode of treatment  was renewed a,t the session of
the Academy, April 4th, and M. Abeille referred  to an instance in which
Aug. Berard lost a patient  from  the peritonitis to which the  injection
gave rise.  M. Velpeau stated that for fifteen years he had been  in  the
habit of  performing this operation, and  in a hundred  cases  which he
had thus treated, he had witnessed no unpleasant results.   Dr. John Wat-
son of this city has had some very successful cases.  One patient, a sai-
lor, wrote to him about a year after  the  operation, that he had had no
return of the hernia, although he had been actively  engaged in the dis-
charge of his ardous duties.  Professor  Parker speaks very highly of
the efficacy of Marsh's truss in accomplishing a radical cure. 
AMERICAN APPENDIX.
907
  Professor Wutzer of Bonn employs the following method of treatment in
the radical cure of reducible inguinal hernia.  After pushing a part of the
skin  of the  scrotum before the fore-finger, a wooden cylinder takes the
place of the latter, through which a needle is passed, a3 well as through
the sac and integuments, which serves, with a screw, to fix and bind the
cover and cylinder together, so that the invaginated skin, the walls of
the sac, and the abdominal integuments are pressed together, with the ne-
cessary degree of force.   The instrument is left in situ for six or eight
days, the effect of which is to produce adhesion of  the whole of the sac,
and to form a firm organic plug filling the inguinal canal.  The patient
is  confined to a sofa  until the needle puncture is healed, and  wears a
truss for  three  months afterwards, to avoid the  danger  of destroying
the new adhesions.   It is not claimed for this method  that it is capable
of effecting a  radical cure in cases where the hernial protrusion is so
large that it  cannot  be kept up by any  mechanical contrivance, but it
so diminishes the difficulty that a truss is effectual in retaining the hernia.
This practice is said to have proved very unsuccessful in  the hands of Pro-
fessor Sigmond  of Vienna, and Rothmund of Munich.   (Lond. Med.
Times and Gazette, May 1854, p. 526.)
                           HYDROCELE.

  We find in the London Medical Times and Gazette, for March, 1854,
p. 217, some clinical remarks by M. Velpeau upon hydrocele, originally
published in the Gaz. des Hopitaux, Feb.  11.   He relates two cases in
which it spontaneously disappeared.  In both there  were transparency
and fluctuation.   A day was selected for the operation, but when the  pa-
tients presented themselves, there was no trace of the disease.   He re-
marks that the different modes of treatment—incision, cauterization, the
seton, &c, are now nearly  abandoned in France, puncture  followed by
injection being  the method almost exclusively  adopted by the  French
surgeons.  Cures may follow the injection of any irritating fluid, but the
injection of iodine possesses an incontestible advantage, because it causes
no inflammation or sloughing  should it escape into the areolar tissue of
the scrotum, and because, from the investigations of M. Hutin, it is now
ascertained that the cure is effected without obliteration  of the  sac  of
the  tunica  vaginalis.  M. Velpeau  refers, also, to a case in which  the
testicle was adherent to the front of the sac, and had been punctured
twice by the trocar.
  In the Ann. de Therapeutique, August, 1847, there is  the report of a
case of  double hydrocele, in which Roux tested the comparative merits
of injections of iodine and of alcohol.   Both  hydroceles were operated
on  at once, and the tincture of iodine used on one side, and alcohol on
the other.   The following circumstances were noticed during the progress
of the case :  1st, the pain was  less from the iodine than the alcoholic
injection ;  2d, the  inflammation caused  by the latter, was more acute,
and of longer  duration  than that produced by the iodine ; 3d, The cure
was accomplished in the  same time by both injections ; 4th, In each case,
the cure was radical. 
908
NEW ELEMENTS OF  OPERATIVE SURGERY
  Notwithstanding the unfavorable opinion of cauterization which our
author has expressed in the text, Prof. Willard Parker of this city advo-
cates the local application of the solid nitrate of silver, which he consi-
ders to possess the following advantages :  1. The ease and safety  with
which it may be performed.   2.  The less liability to severe inflammation.
3. The certainty  of success.  He has reported some cases illustrative
of this method of treatment, in the New-York Journal of Aledicine,  Jan.
1854.
            HYDROCEPHALUS, PARACENTESIS IN

   Dr. Charles West published in the London  Medical  Gazette for
April, 1842, " An Inquiry  into the Results  of Puncture of the Head,
in cases of chronic Hydrocephalus."   He has collected some 56 cases,
in which this operation has been performed, and in 16 it is said to have
been  successful.   To  these  we have  added  14 other cases, which we
have found  recorded in  the  journals  or obtained from private sources,
and in  only  3 of these  is it reported as successful.  Thus out of 70
cases, we  have but 19  cures.  But before a patient can be regarded as
cured, years must have passed without a return of the disease, and we
fear, that, if subjected  to this  test, we should have in reality but very
few cures.   In many, if not in the majoi'ity of the cases in which the sur-
geon's interference is requested, the condition of the brain is such, either
from an arrest of development, or other degenerations, that no reasonable
hope can  be entertained of effecting a removal of the disease.  In one
case, we operated for the purpose of saving the parents from the shock
of witnessing the sudden death of  their child, by the spontaneous open-
ing which, from the enormous distention of  the parts, seemed not far
distant.  As will be seen  by the  following  cut, the head  was of an
extraordinary size and shape, and it was perfectly transparent.

                               Fig. l.
 
AMERICAN APPENDIX.
909
  The child was  six  months  of  age, its  health  good, nutrition  well
performed, and  with  the  exception of the threatened rupture of the
cranial coverings, there were no indications of immediate danger to life.
The head began to enlarge shortly after birth, and continued to increase,
until  it was about four months old, when,  during the night, the cranial
cavity became at once nearly empty, whilst the integuments covering the
entire body were  distended as in anasarca.  In the  course of a few
days, the latter completely disappeared, and the head regained its accus-
tomed extraordinary size.  On the 6th of May, 1850, with the point of
a narrow bistoury, a puncture was made through the thin and distended
coverings of the cranium, and  about six or  eight ounces of fluid  were
allowed  to  escape.  As no  immediate unpleasant effects followed, the
operation was  repeated at intervals of two or three days ;  and in the
course of ten days, between two and three  quarts of fluid had been  evac-
uated.  On the 18th of-May, after a  few hours of suffering, the  child
died.   At the autopsy, an ordinary sized wash bowl was filled with the
fluid emptied from the cranial cavity.   There were no traces of cerebral
substance, but at the base of the  brain the pons varolii and medulla
oblongata were found of their natural size and shape.   We were after-
wards consulted as  to the propriety of an operation in the case represen-
ted by Fig.  2.

                               Fig. 2.
    Every portion of the cranium was of stony hardness, and with no
 amount of pressure with  the fingers could we produce the  slightest in-
 dentation.   The  patient was frequently affected with convulsions and
 other symptoms  of cerebral disturbance.  Believing the case to be one
 of hypertrophy, not only of the brain but of the bones of the skull, we
. declined any interference ;  for if paracentesis is ever justifiable in chronic 
910
NEW ELEMENTS  OF OPERATIVE  SURGERY.
hydrocephalus, in  hypertrophy of the  brain, it  can only be productive
of mischievous results.
  A diversity  of  opinion seems to prevail  among surgeons as to tho
propriety of operating in chronic hydrocephalus.
  Mr. Fergusson regards the operation as worthy of trial, and relates
several  instances  in  which it has been  performed by himself  and his
friends.  He states that, although his own experience does not enable
him to be very  sanguine of great success from this proceeding, yet that
which  has been obtained bv others is, in his opinion, a sufficient sanction
for a continuance of the practice in all" favorable-looking cases." (Prac-
tical Surgery, 3d Lon. Ed., p. 556.)
  Dieffenbach is strongly  opposed to  the operation, having, during the
earlier part of his professional career, had  three unsuccessful cases.
Although success may in  some few cases have  followed it, yet  on the
whole he is disposed to consider them as fortunate escapes, like  those
which have been recorded in which a sailor recovered after a ship's an-
chor had passed through  his abdomen, or the shaft of a cabriolet had
pierced the thorax of a  coachman, &c, &c, upon which cures a surgeon
has no right to calculate.   ( Operative Chirurgie, Zweiter Band, Leipzig.
1848, p. 9.)
  Dr. Battersby states that he is acquainted with ten cases in which the
operation  has been  unsuccessfully tried in Dublin, and there can be no
doubt that a large  number of fatal cases remain, and will ever remain
unknown.   We have been informed by Prof.  Stevens, Parker, Dr.Wat-
son, and  others in this city, of several cases in which the operation has
not averted a fatal termination.   Still, we feel persuaded that, in cases
similar to our  own, and  for  the  end  proposed in this case, a surgeon
would be justified in resorting to it.
  Dr. Watson,  in  his Lectures  delivered at King's College Hospital,
Am. Ed. p. 284, remarks : "He  must  have  been a bold physician who
first proposed to decant the water from the brain, by means of a perfor-
ation, made  with  a trocar, through the  membrane of the fontanelle,
through the  membranes of the  brain, and through even the expanded
cerebral substance itself.  But the success of the project has amply vin-
dicated this happy audacity.   Though denounced as useless and cruel by
some  high continental  authorities, by  Gjlis  and Richter especially, it
furnishes one of the best of the few chances of safety to the patient.  Of
course, I mean  ultimate safety, for the operation itself is attended with
the present risk of accelerating the patient's death.  We have to consid-
er that, by performing the operation, we incur the danger of abbreviating
the existence of a being  whose life without it could scarcely be long con-
tinued, or capable of enjoyment, but  then we afford  some chance  of
a perfect  cure.  A speedy death,  or an uncertain life of mental and
bodily imbecility, or complete restoration—these are the three events  to
be looked at.   Had I to decide the painful question in reference to one
of my own children, I would accept the alternative of probable  speedy
death on the  one hand, or possible complete recovery on the other."
  The instrument employed in this operation may be a small trocar, or
a narrow pointed bistoury.  The punctures should not be made  too fre-
quently, nor should too  large a quantity of fluid be withdrawn at  once.
As the cranial cavity becomes diminished in size, gentle support must bo 
AMERICAN APPENDIX.
911
made with straps of adhesive  plaster and bandages, and  if the child
sink rapidly, resort  must be had to stimulants.  For  further details
connected with  this  subject we  would refer the reader to a statistical
paper published  in the New-York Journal of Medicine, May, 1854, in
which  we have  endeavoured to embody  all the  facts of importance to
those who propose to undertake this operation.
  The  following note is from the Appendix by M.  Velpeau, in the last
edition.
  A new case of hydrocephalus cured by compression, in a female infant
aged twenty-seven months, has been communicated  to me by M. Lowen-
hardt,,  (Journal des Conn. Med.-Chir., t. xii., p. 257;  Encyclogr.  des
Sciences Mid., 1839, p. 177.)  A hydrocephalic child, treated by punc-
ture, in the practice  of M. Tetlow, (Gaz. des Hopit., 1839, p. 185,) was
much relieved, but died on the. tenth day  of an acute bronchitis.
   HYSTEROTOMY ABDOMINAL, OR CESAREAN SECTION.

   According to the statistics collected by Dr. Churchill and  published
in his Theory and Practice of Midwifery, Phil. 1853, p. 365, it  ap-
pears  that of 433 cases of this operation, it was fatal to the mother, in
197 instances, being a mortality of about 1 in 2\\ cases.  Of the infants,
175 were saved, and 71  lost.  Dr. Charles West has written a very
valuable paper on the dangers of this operation, which may be found
in the Medico-Chirurgical Transactions, Vol. xxxiv. 1851.   In his  re-
marks he notices; 1. The danger from hemorrhage, which  differs in
character from that in any other operation, and is not capable of being
arrested by the same means that suppress it under ordinary circumstances.
   2. The shock inflicted  on the nervous system, as well by the violent
interference with the most important process that ever goes  on  in  the
organism within the same limited time, the uterus of a parturient woman
being, besides, so liberally supplied with  nerves.
   3. The hazard inseparable from extensive injury to the peritoneum,
when unblunted in its sympathies and unaltered in its texture, as in cases
of ovarian  or other tumors for the removal of which a similar exposure
of the abdominal cavity is sometimes practised.
   4. The danger resulting from the infliction of a wound on the uterus,
at a time, when in the ordinary course of things, the processes which nature
is prepared to carry  on in it, consist in the disintegration  and removal
of its tissue, the reverse being essential to the repair of injury.
   In 147 fatal cases  collected by Dr. West, hemorrhage either during
or subsequent to the operation, occurred in 41; and  in a third of this
number was the sole cause of death.   In 7, it was  caused by a wound
of the placenta, an accident which Dr. W. thinks may be avoided in  the
majority of instances, by careful  preliminary auscultation.  Secondary
hemorrhage is very difficult to controul;  the incision through the uterine
substance, of course, seriously impairs  its contractible  power, and  the
peculiar  arrangement of the uterine  sinuses which, in natural parturi-
tion serves to prevent the  occurrence of hemorrhage after the separation
of the placenta, even when the uterus remains uncontracted, can here be 
 912            NEW ELEMENTS OF  OPERATIVE SURGERY.

 of no service in arresting  the bleeding  from the wound.  Dr. W. dis-
 cusses  the influence of anaesthetic  agents in favoring this hemorrhage,
 which was serious in 4 out of 7 cases in which they were employed.   In 2
 of these, however, the action of  the uterus continued vigorous, although
 the patient was rendered completely insensible ; and in  another, (Mr.
 Skey's, at St. Bartholomew's) which it was our privilege to witness, the
 patient was at no time fully under the influence of ether, and in the fourth
 case, (Dr. Niramo's) the placenta  was  wounded.   Dr. W. asserts that
 the risk of serious hemorrhage is diminished by not operating till after
 the liquor amnii has escaped, or been  evacuated.   The danger of excit-
 ing violent peritoneal  inflammation, he considers a sufficient  reaaon for ^
 rejecting the practice of Professor Ritgen of Giessen, who advises that *
 the uterus be drawn forwards, and  surrounded  with sponges  dipped in
 cold  water, till vigorous and permament contraction has been induced.
   The shock to the nervous system is a very serious  cause of the mor-
 tality after this operation.   In 33 of 147 fatal cases, the  patient sank
 under the shock, no hemorrhage  having attended or followed the  opera-
 tion, and no  morbid appearances having been discovered after  death.
 In 56 death seems to have been caused  by peritonitis.  Another  cause
 is the great difficulty in procuring union  of the divided uterine surfaces,
 which, even when it occurs, is  almost  invariably accomplished in an im-
 perfect manner.  In view of all  the risks  connected with this opera-
 tion, Dr. West observes:
   " If then such and so many dangers beset this operation, if  the  recov-
 eries be so few, and the mortality so great, while the causes of that mor-
 tality are, for the most part, beyond the  power  either of surgical dex-
 terity or medical skill to obviate, and some of them  inseparable  from
 those processes which needs must follow  delivery,  we may, I  think, feel
 satisfied that the general rule in British Midwifery, which  prohibits the
 performance  of the Csesarean section, except where  delivery  would
 otherwise be  altogether impossible, rests on a far  sounder foundation
 than  that of mere prejudice, or blind obedience, to the dicta of men em-
 inent in their profession.  At the same time, these facts can yield  no
 apology for those who, in cases calling  for this operation, allow, from
 any cause whatever, the right moment to  pass by unused.  They rather
 leave such conduct altogether without excuse, since, by it, dangers always
 great  are rendered insurmountable, and hopes, small at the best, are
 utterly destroyed."

                        Hysterotomy  Vaginal.

   Several cases of partial or complete occlusion of the os uteri requiring
 incision during labor have been recorded within a few years past.   Pro-
 fessor Bedford ha3had two cases, the first of which was reported  in the
 New-York Journal of Medicine  for  March, 1842; the second in the
 American Journal of Medical Sciences,  for April, 1848.  In the same
journal for October, 1847, may be found  the account of  another case by
 Dr. Buckingham.  A case  has also occurred in the practice of Dr. S.
 Tyler, of Maryland, and of Dr. Wm. H.  Reynale of Buffalo.
  The late Dr. Dewees, in  his Compendious System of Midwifery has
 given us the  details  of a case in  which  an anterior  obliquity  of the 
AMERICAN APPENDIX.
913
womb was mistaken for an occlusion of the os uteri, and vaginal hyster-
otomy performed !  " The woman recovered, and  to the disgrace of the
accoucheurs who attended her, was delivered, per vias naturales, of sev-
eral children  afterwards,—a  damning  proof that the operation was
most wantonly performed."  Dr. A. Willard, of Greene, N. Y., has pub-
lished in the New-York Journal of Medicine for March, 1855, a valua-
ble paper entitled " Remarks on Occlusion of the  Uterus,  with a case."
In  this  he attempts to prove, and we think successfully,  that many of
the reported cases  of occlusion of the uterus have been  nothing more
than obliquity of the os uteri.   From the well known difficulties in pro-
curing adhesions of the surfaces of mucous membranes, and the peculiar
manner in which the  orifices of mucous  passages  have been guarded
against such an accident, he argues that atresia uteri, must be very rare
indeed.   His analysis of many of the cases reported as such, has satis-
fied us that serious  errors have been committed, as in that related by Dr.
Dewees.  His  examination of Dr. Bedford's report  of  the operation
which he performed  in  the  presence of  Dr. Mott, shows conclusively
that the operator has been guilty of curious inconsistencies  in his account
of the case.  We present the reader with the concluding remarks of Dr.
Willard.   " Has any  post-mortem  examination  ever been  made that
would show distinctly  the fact, that organized adhesion of the entrance
into the womb has  ever yet taken place in the impregnated state ?  Wo
have seen none.
  We conclude, that although the operation of vaginal hysterotomy is
almost entirely devoid of danger when properly performed, and at the
proper period, yet it is one that is very  seldom required, and  that the
circumstances calling for  it will most frequently be found in  diseased or
abnormal conditions of the muscular structure of the neck  of the womb ;
for  instance, when the muscular structure of the cervix uteri  is changed
in character, or destroyed by  disease or mechanical injury, or when
there is congentile  defect in it.  This idea, we think, will be found to
apply as well to cases termed rigidity of the os uteri as to those in  which
there is supposed to be an entire occlusion.   We see no especial  differ-
ence.
  In the present state of our knowledge, and until some remedy can be
found that will equalize the action of the uterus (so to speak) and produce
" pains " which shall be  both perfect and  regular, it is possible that  a
case may occur in which incision will become necessary, to relieve some
obstinate  muscular  contraction of the os uteri:  such  incision, however,
would not ordinarily regulate the uterine action, and the probable result
would be, delivery with the forceps."
                         IRIDOPLASTY.

  We  copy from  the American Journal of Medical Sciences, for Jan.
1855, the following curious, and probably unique case.   The operation
was performed by Dr. Alessi, of  Rome, and was reported in the Archives
dy Ophthalmologic, for  Feb.  1854.   The  patient was affected with cap-
sulo-lenticular cataract, with spontaneous displacement of the crystalline
   Vol. III.                   115 
914
AMERICAN  APPENDIX.
 lens, complicated with chronic retinitis.  The cataract was soft and large,
 and pressed the iris forwards so as almost to completely  obliterate the
 anterior chamber.   The patient suffered such acute pain that he earnestly
 requested an operation for his relief.  Though foreseeing the difficulties
 he  would  have to encounter from the absence of the anterior  chamber,
 and the probable  softening of the vitreous humour, Dr.  A. yielded to
 the  urgent and repeated  solictations of the patient, and determined to
 extract the lens.  Placing the patient in a recumbent position, ho made
 the  inferior  section of the cornea ;  but in doing this, owing to the iris
 being almost in contact with the posterior face of the cornea, the iris
 was cut, and the capsule of the lens at the same time opened.  The lens
 passed  out  through the incision without  difficulty.   Immediately after-
 wards it was observed  that there was a transverse elliptical opening at
 the inferior portion of the iris, forming a true artificial pupil, which was
 separated from  the natural pupil by a band of about three  to four milli-
 metres  broad.  There  was also in  the upper portion of the  posterior
 chamber a portion  of opaque capsule.   The operator endeavoured, by
 slight pressure on the upper part of  the eye, to force down this portion
 of capsule so as to extract it through the wound in the cornea.  But he
 was unable to force it into the wound in the cornea ; he could only press
 it  into  the  wound  of  the  iris.   He  however observed that,  when the
 pressure was discontinned, the capsule seemed disposed to remain in the
 wound in the iris, and to block up the artificial pupil.   Dr. A. determined
to  take  advantage of this happy circumstance, and, after  engaging the
capsule  as far as he could in the wound in the iris, he desisted  from fur-
ther attempts, trusting that adhesion between the capsule and iris would
take place, and  the wound in the iris thus fill up.  The hopes of Dr. A.
were entirely realized.   At the end of eight days, Dr. A. had  the satis-
faction of finding that the patient had received no injury either from the
operation  or  from  the  wound of the  iris, that the fragment of capsule
Was firmly adherent to the iris, and that the artificial pupil was thus en-
tirely obliterated.
               LARYNX, MORBID GROWTHS  IN.

  Since the  publication  of Prof  Ehrmann's  Histoire des Polypes du
Larynx, in 1850, the attention of the profession has been called to the
existence  of  morbid growths within the larynx, which in many  cases
admit of relief by surgical operation.   Among our own countrymen who
have contributed most to the  advancement of our knowledge on this
subject, the names of Profs. Parker, Green, and Dr.  Buck deserve to be
mentioned.  The latter gentleman has written a statistical paper of all
the cases recorded, which was published in the sixth volume of the
Transactions of the  American Medical Association, 1853.  He has col-
lected in all 42 cases, and in some of these the morbid  growth was suc-
cessfully extirpated,  by Profs. Ehrmann and Green.   Dr.  Buck himself
was less fortunate.   The proper remedy for the majority of these  cases
is  to  open the cavity of the larynx thoughout its whole extent, as was
done by Prof. Ehrmann, after which the morbid growths must be excised, 
NEW ELEMENTS OF  OPERATIVE SURGERY.
915
the trachea being also opened at its upper part, and a tube inserted to
maintain respiration.  In  one of the cases reported by Dr.  Green, the
polypous growth was expelled from the cavity of the larynx in the act
of coughing, and brought within view at the side of the epiglottis, where
it  was seized by a double hook and removed.  The first notice of this
disease published io. this country, was by Dr.  John C.  Cheesman, in the
Transactions of the Physico- Aledical Society of New-York, 1817, vol. 1,
p.  413.
                           LITHOTOMY.

   In the appendix to the last edition, M. Velpeau notices the following
 cases:
   M. H.  Thomas, (L. Experience, t. iii., p. 301,) an English  surgeon,
 following M. Philippe, of Reims, has performed the operation of lithoto-
 my ^with success, upon a pregnant woman.   Having, in a case of my own,
 a stone of three ounces weight to remove from the bladder of a woman,
 I concluded to adopt the vesico-vaginal method.  This  appears to have
 been the first time this operation  was performed at Paris.  Operating
 upon an adult by the high operation, the 18th of June, 1815,1 succeeded,
 says M. Champion, in extracting two stones, one of the form of the little
 finger, and somewhat larger in size, and  which  had entered by one of
 its extremities into tht left  ureter ; the other weighing thirteen and a
 half ounces.  The volume  of  this stone obliged me  to detach the peri-
 toneum above the superior portion of the bladder, in order to carry my
 incision in the  latter to more than three inches  in extent.   The stone
 was so strongly embraced that it was impossible to introduce the forceps
 even  when they were unjoin ted, in order to seize and to hold it, which
 compelled me, says the author, to employ a curved lever, with which I
 had provided myself, and which I cautiously insinuated beneath in order
 to raise it gently, that I might disengage it from its bed, while I support-
 ed it with the hand that was free.  The internal coat  of the bladder
 was lined throughout with a false membrane, strewed with coarse sand,
 resembling a thick wet spider's web  covered with gravel.  At the  end
 of some  days, this false membrane, which I had intended to attack by
 solvents, detached itself by fragments, which made their way to the wound
 in the hypogastrium, and thus enabled me to extract them.  The patient
 recovered perfectly.
   The difficulties that I encountered in this case, says M. Champion,
 were necessarily numerous, for  they were the consequence  of the long-
 protracted retention  of the  calculus, and the size this  body had acquired.
 I know that in one case, Deguise, the father, could not  seize the stone
 after  the  incision by the high  operation, and that he was obliged to
 force it upward  by aid of  a forceps, or a curette introduced by tho cut
 through the  perinaeum.  More recently, one of the distinguished sur-
 geons of the capital,  assisted by one of  his brethren not less skilful, was
 much embarrassed in a similar  case, by reason of  the narrowness of the
vesical  cavity, a  circumstance which determined  them to  perform  the
recto-vesical incision, by which the stone, in fact, was extracted.   The
case of M. Leonardon much resembles  the preceding.   The  stone  ex- 
916
AMERICAN APPENDIX.
tracted by M. Champion has been deposited in the cabinet of the Faculty,
and the curved  1
partie chir., t. ii
planches, par  Alb
polypi in  the  vagina, and  to  serve  as  a guide to  the  ligature-carrier,
(porte-anse,~)  is the instrument that he made use of.
   Professor Willard Parker, of the College of Physicians and Surgeons
N. Y., is an advocate for the high operation for stone in the female.   In
the New-York Journal of Medicine  for March, 1855,  he has  reported
three cases in  which  he had resorted to  this method with the most grati-
fying results.   The following is the proceeding which he adopted:
   First.—The patient was put fully under the influence of  chloroform.
   Secondly.—The bladder was injected with flax-seed tea, and owing to
the system being under the influence of  the anesthetic, the injection was
introduced without any resistance, and the organ well filled.
   Thirdly.—An assistant prevented the escape of the fluid, by pressing
the urethra against the put>ic arch.
   Fourthly.—The pubes  being well shaved, I made an incision along the
linea alba, through the fat and muscles,  until I reached the bladder.
   Fifthly.—I  now hooked strongly through the bladder, by large tenac-
ula, and gave them in charge of assistants.   I then punctured the blad-
der with a pointed bistoury, and made an incision  about one and a half
inches in length.  No regurgitation took place.  Upon my finger I intro-
duced the  ordinary  nasal polypous  forceps, and  easily removed the
stone.
   Sixthly.—The assistant now removed his  finger from the urethra, the
fluid escaped,  and the hooks were removed.
   The upper part of the wound was closed with a suture and straps, the
lower portion  being left open for the escape of any discharge.
   Infiltration of urine  is effectually  prevented by hooking up the walls
of the bladder, before the latter is opened, a  precaution which according
to Prof. P. should never be omitted.   The high operation, although not
tree  from difficulties,  as  proved by the cases above mentioned by our
author, is the only one which insures the  patient against that incontinence
of urine which is one of the most disagreeable  consequence* resulting
from the ordinary operation.  The dangers of urinary infiltration, hemor-
rhage, and wounds of the peritoneum,  which  have  been urged  as ob-
jections to this  proceeding, Prof. P. considers as due to the method of
operating or the carelessness of the operator, rather than to any neces-
sary result of the operation.   Another objection, which has been regard-
ed as rendering the high operation impracticable, is removed by the use
of anaesthetics   We refer to those cases in which the irritability of the
bladder is such as to prevent its distension by means of  injections.
   In a summary of the cases of lithotomy which occurred in the London

Gazette, March 18o4,) it would seem that  the ratio of mortality after
 his operation  at the  present day, in those institutions, is far higher than

he W W20  ? r6  10*3 fTUt °f,213 CaS6S at  St Thomas Hospital,
of iTol1   fi'      '? ) f' ^freaS« duHnff the Period ab°™ referred to
Kthotnm   i, Jl™ i  i       miflUeDCe °f  age UP°n the mortalitv after
lithotomy, is strikingly shown in the recent  cases above  mentioned   20 
NEW ELEMENTS OF  OPERATIVE SURGERY.
917
of the 28 cases, were boys, and of these only 2 died, while in the adults,
one half died !   Prof. Simpson, in his Statistics in Surgery, published
in the Edinburgh Monthly Journal, November 1847, p. 325, has thrown
all of Cheselden's 213  cases  into a tabular  form, for the purpose  of
showing that  the danger of lithotomy increases in a ratio  progressive
with the age of the patient.
Ages of the Patients.	No. of Cases _105— 62 22 24	No. of Deaths	Ratio of Mortality	Per Centage of Deaths
Under 10 years From 11 to 20 yrs. From 21 to 40 yrs. From 41 to 80 yrs.		3 4 5 8	lin 35 1 in 15J 1 in 4f lin 3	3 in 100 6 in 100 22 in 100 33 in 100
  The following  Table shows the influence of the weight of the stone
upon the mortality.
Weight of Stone	No. of Cases	No. of Deaths	Ratio of Mortality	Per Centage of Mortality
2 oz. and under From 2 to 4 oz. From 4 to 7 oz.	648 46 9	65 23 5	1 in 9g lin2 linli	10 in 100 50 in 100 55 in 100
  Mr. Coulson, in his recent work on Lithotrity and Lithotomy, (Lond.
1853) states, that in 2,972 cases, in which he has  examined  the influ-
ence of age upon the mortality after lithotomy, he finds, that,  below 10
years, it is 1 in 13, and thence gradually augments from 10 to 80 years
to 1 in 9,  1 in 6, 1 in 4, 1 in 3.65, 1 in 3.23, and 1 in 2.71.
  As to the influence of the  method employed, he observes, that of
4793 cases, Cheselden's operation stands at the  head  of  all, the mor-
tality in upwards of 2000 cases, having been 1 in 7.38.  The apparatus
major comes next, a result for which I confess that I was not prepared.
In nearly  2000  cases, the mortality was 1 in 4.89.  The  recto-vesical
follows close on  the  apparatus major, giving a proportion of 1 in 4.87.
Then comes Dupuytren's bilateral operation, with a mortality of 1 in 4;
and, finally, the  high operation, which in 268 cases gives a mortality of
lin 3.08.
  For further information on this  subject, we must refer the  reader to the
work already quoted, or to the most  excellent treatise  of our country-
man, Professor Gross.
                          LITHOTRITY.

  Nearly thirty years have passed since M. Civiale performed his first
operation for lithotrity, and twenty-five since it was first performed at
Westminster Hospital, London, yet Mr. Coulson in his treatise of 1853,
states that, " In this country we have contributed little or nothing to the
statistics of lithotrity,"  p. 380.   Mr. Skey, however, in his work  on
Operative Surgery, published since 1850, declares that in London, lith-
otrity is the rule, and lithotomy the exception, and in the account of the 
91S            NEW ELEMENTS OP OPERATIVE SURGERY.
 proceedings of the Pathological Society of London, reported in the
 Lond. Med. Times, for December, 1850, it is stated that Mr.  Charles
 Hawkins (Sir Benjamin Brodie's assistant) remarked that he had seen it
 performed several hundred times; from which we infer that it is a favor-
 ite proceeding with Sir Benjamin.  According to the report published in
 the Lond. Med. Times and Gazette, to which we have already alluded,
 of the 32 cases of stone which presented themselves at the London  Hos-
 pitals, during the last six months  of 1853,  lithotrity was performed in
 4 only.  No less than 2 of these were  fatal!  And yet in the hands of
 M. Civiale, lithotrity is said to prove fatal but once in 40^ cases !  In
 this country this operation is performed by a comparatively small num-
 ber of surgeons, but we think from present indications that it is likely to
 become more generally practised.
  In the appendix to the last  edition, M. Velpeau  had the following:
 " A curious case of lithotrity has been  published by  M.  Taron, (Ibid.,
 1839, p. 266.)  A man aged thirty years, introduced a shoe-tie into the
 bladder; lithic concretions gathered upon this foreign body, which three
 or four applications of lithotrity  sufficed to break up  and extract.   By
 further information we learn that this patient died, in consequence of the
 operation, (Journal de Scalpel, No. 1, Juin, 1839.)   I myself, in June,
 1839, cured a young man of eighteen years, in a single sitting, at lithot-
rity, of a calculus of eight lines."
                   LIVER, PARACENTESIS  OF.

  The late Dr. J. Edward Weber, of N, Y., performed the following ope-
ration  in  a case of hepatic hydatids.  The bowels having  been freely
moved, an exploring trocar was  thrust a few inches through the integu-
ments into the most prominent part of the swelling,  the sensation caused
by the  passage of the instrument being similar to that  perceived in pa-
racentesis abdominis.  On withdrawing it, a fluid resembling whey dropped
from its orfice, the microscopical examination of which revealed  nothing
remarkable.  A longitudinal incision, two inches long, beino- then  made
down to the liver, a direct puncture  of the  liver  with the °trocar   gave
the same  results.   There was no union  of the peritoneal surfaces/and
to effect this  a well oiled tent was introduced upon the peritoneum, the
end of the tent  being left in the  lower angle  of  the  wound.  During
six days the^ patient complained of slight  pain in  a circumscribed region,
about the size  of the  hand   In the course of  eighteen  days.it  being
supposed that adhesions had formed, the second operation was  commenc-
ed.   The  first incision having contracted, it was enlarged upwards of
an inch, when, the finger  having detected perfect  adhesions between the
abdominal peritoneum and that covering  the liver, an  incision  was made
trough the parietes of the liver into the cavity of the  cyst, which  was
thought to be  o   the size of the adult  skull.  The  contents, consisting of
a fluid and small cyst, were now cautiously evacuated,  another oiled  tent
introduced as before  and twenty-two months after  the operation the
patient  recovered.. (New-York Medical Times  May 1852)
  Dr. F. A. Aran, Physician to St. Antoine  Hospital,  Paris, has reported 
AMERICAN APPENDIX.                    919
m the  Revue Med. Chir. de Paris, torn. XVI, a case in which, after ten
successive  punctures, the following fluid  was  injected—tinct.  iodine,
§ii.; aqua destil, |ii.; potas. iodid. 5iss.  No pain ensued, and the  cyst,
which had previously contained thirty-two ounces of reddish fluid, slowly
contracted.  A brief notice of this case may also be found in the British
and Foreign Medico-Chirurgical Review, for January, 1855, Am. Ed.
p. 211.
   A very interesting  case of hydatid  disease  of the liver  cured  by
operation, has been reported  by Dr. Owen  Rees, in the Guy's Hospital
Reports, Second Series, vol. vi., Part I. October, 1848.
                        CESOPHAGOTOMY.

  Dr. John Watson, of the New-York Hospital, has performed this very
rare operation, in a case of organic obstruction of the cesophagus.  A
report of it may be found in the American Journal of Medical Sciences,
N. S. Vol. VIII., p. 309, 1844.  We  copy his description of the pro-
ceedings adopted :—
  An incision was  commenced on  the left side of the neck, midway be-
tween  the os-hyoides and the upper border of the thyroid cartilage, just
in front of the sterno-mastoid muscle, and carried "down  parallel with
the edge of this muscle to within an inch of the sterno-clavicular articu-
lation, dividing the skin, superficial fascia, and platysma-myoides muscle.
  A second incision, nearly an inch in length, was now made nearly pa-
rallel with the upper edge of the thyroid cartilage, terminating posteri-
orly at the upper extremity of the first and extending to the same depth.
After turning up the flap at the angle of these cuts, a glandular tumor,
about the size of a hazel-nut, was exposed and removed from among the
layers of  the  deep fascia.   It proved to be very hard, and contained a
yellowish concrete pus in the centre.  The dissection being then contin-
ued through the deep fascia, the omo-hyoid muscle was exposed and di-
vided ; the  superior  thyroid  artery brought into view, secured by two
ligatures, and divided between them and the loose  cellular tissue be-
tween the carotid and the  trachea, separated by the handle of the scal-
pel until the lower portion of the  pharynx and part of the  cesophagus
were fairly exposed, this structure  being  put  upon the stretch at every
effort  of  the  patient to swallow.   The edges of the wound being then
dilated by  curved spatulas, an attempt was made to seize and puncture
the wall of the  pharynx, but owing to the difficulty of accomplishing it
without endangering  other  parts, a silver catheter was   introduced
through the  mouth to the stricture, and, its point  being cut upon, the
oesophagus was opened.
   On  passing an instrument into the opening, the seat of obstruction was
found to  be just below the incision but within reach of the finger; and,
as  there was danger of wounding the  ascending thyroid artery, in an at-
tempt to  divide it from  within, it  was found  necessary to open it from
without.   In order to obtain room, the sterno-mastoid muscle was there-
fore divided transversely, and the upper border of the thyroid  gland
turned down.   The recurrent nerve being now brought into view, one of 
 920           NEW ELEMENTS OF OPERATIVE  SURGERY.

the branches of the superior  thyroid artery was divided as it entered
the gland, giving rise to the only hemorrhage during the operation that
required attention, and this being arrested, the division of the stricture
was effected by an incision through it of  at least an inch and a half in
length, the obstruction depending apparently on a simple induration and
contraction of the part not over five or six lines wide.  A stomach-tube
being now introduced through the wound, wine and arrow-root were ad-
ministered.   This tube  was then secured to the side of the head by its
free extremity, the transverse  portion of the wound closed by a single
suture, and  the  remainder allowed to remain open.  At the end of six
days, the tube being removed, a second one was introduced through the
nostril,  down through the stricture, and  worn  twenty-five days, the
wound being closed by adhesive  plaster.   Several changes in the cathe-
ters being made from time to time, the  patient continued wearing them
for nearly seven weeks, the wound having healed around it.  At the end
of this period, the tube was withdrawn on account of the irritation in the
throat, the obstruction in the oesophagus  re-appeared, so as to require
the re-opening of  the wound in the neck, and the patient died about three
months subsequently.
  Dr. Watson was unquestionably the first to cut down directly upon the
seat of stricture and to divide it, in the same manner as Professor Syme
operates for stricture of the urethra.  The oesophagus  was long since
opened below the  seat of obstruction,  for the purpose  of introducing
nourishment into  tho stomach.   Morgagni in  his  Epistles, (28, p. 36,
ed.  Chaussier et Adelon) refers to a case in which this proceeding was
adopted by Stoffel, and in the Journ. de Med. et Chir. &c., t. 68, p. 250,
Taranget has  related another, in  which life  was prolonged for many
months by a similar operation.   M. Follin,  in his very interesting mono-
graph " Des Retrecissements de V GEsophage," Paris, 1853, p. 116, states
that M. Monod, some years since, performed cesophagotomy on a female
affected with cancer of the lower part of the  pharynx and the adjacent
portion of the cesophagus; but although the operation answered the end
proposed, viz. the alimentation of the  patient, yet she died some three
months afterwards, from the progress of the disease.
  Again, M. de Lavacherie, of Liege, has performed this operation above
the seat  of obstruction, with a view  to facilitate  the dilatation of the
latter by means of bougies, and at the same time to introduce food into
the stomach.   M. Follin relates this case in detail; op. cit. p. 122. The
patient died on the fifteenth day.
  In concluding the report of his case, Dr. Watson suggests whether as
an extreme  measure—making an opening into  the stomach for the pur-
pose of introducing nourishment, would not offer as many advantages in
similar cases, as cesophagotomy.  He adduces several facts  which lend
considerable support to the proposition.  Dr. A. Egelberg, a Norwegian
surgeon, proposed a similar measure in 1837.  Experiments made upon
animals have shown that life may be thus  prolonged, for a considerable
period.   M. Blondlot.refers to a dog in his possession, which had  lived
in this manner for two years. (Traite Analytique de la digestion, p. 205.)
The possibility of nutrition being thus maintained, has also been confirmed
by the recent experiments of M. M. Sedillot and Claude Bernard.  In-
deed M. Sedillot has twice  performed gastrotomy on tho human subject 
AMERICAN APPENDIX.
921
with the object above recommended, but both of his patients died, one
from peritonitis, whilst in the other case, the autopsy did not clearly dis-
close the cause of death.  Full reports of these operations may bo found
in the work of M. Follin, pp. 139, 152.
  In March, 1853, Dr. Fenger, of Copenhagen,  performed  gastrotomy
in a case of stricture of the oesophagus, the result of carcinoma.  The
patient died 58 hours after  the operation.   In the report of the autopsy,
no mention is  made of peritonitis, nor are we informed of the cause of
death.   For further particulars, see Virchow's  Arch, fur Path. Anat.
Vol. VI., or Rank's Abstract, Vol. XX.,
  In the Pfiiladelphia Medical Examiner, for April, 1855, maybe found
a successful case  of gastrotomy, performed by  Dr.  Bell, of Wapello,
Iowa.   This case we insert in detail under the head of Gastrotomy.
                       OPHTHALMOSCOPE.

   This is the name of an instrument recently devised to assist in our
examination  of  the  interior  structures of the eye.  The original in-
strument of Helmholtz, has been more or less modified by Epkens, Coccius
of Leipsic, and  others.   Perhaps  the  best  modification yet proposed  is
that by M. le Docteur Anogwastake's, a Greek.  His instrument consists
simply  of a  concave mirror, whose  diameter is  about two inches, and
whose focal distance is from four to five.   The convex surface is coated
like  the common mirror, and covered  by a thin plate of copper colored
black, which extends sufficiently over the circular edge of the mirror to
hold it in its position, somewhat as the watch-crystal is confined.  The
instrument is pierced by a small overture in its centre, about the size of
a writing quill.   This opening is infundibuliform at the anterior base.
A small handle  from three to four inches  long, as fancy  dictates, is
attached to the circumference of one side, to maintain it when held before
the eye.  It  resembles  an American dollar, concave, and placed in  a
very small circular frame, with a stem  or handle projecting horizontally
to its  surface, with one  side covered  and coated with colored copper,
and the two pierced in the centre.  The pupils having been dilated with
belladonna, or atropine, the patient is seated in a dark room by the side
of a table upon which is placed a lamp with a glass chimney, and in which
oil is used.   The light must be on a level  with the eye to  be examined.
The  operator is seated before  the patient and at the same height.   He
holds the instrument with the mirrored surface towards the patient,  and
the posterior surface is  applied against his own eye, so that he may be
able to look through the small aperture.   This being done, the surgeon
turns the instrument a little without, in such a manner that the flame of
the lamp shall strike upon the bright  surface of the mirror, which reflects
it upon the pupil of the eye.  This  reflection, to be satisfactory, ought
to be oblong, strait,,and very brilliant, which can be obtained easily by
approaching, or withdrawing a little from the  patient, as the case may
demand.  Thus  the rays from the lamp can be thrown into the dilated
pupil, thereby illuminating the chambers of  the eye and its deeper struc-
tures, so that the operator, posted behind his little mirror, can send his
  vol. in.                     116 
922
NEW ELEMENTS OF OPERATIVE SURGERY.
 own vision through its opening in search of the mote that is in his brother's
 eye.
   In examining the retina, the surgeon  must often place himself at a
 greater or less distance from  the patient, or he may approach the lamp,
 in order to elongate the focus.  This instrument is said to have cleared
 up  the  diagnosis in some very doubtful cases, having detected opacities
 of the lens, and of the vitreous humor when the naked eye had failed.
 For a description  of the above modification, we are indebted to a com-
 munication from Dr. A. B. Hall, (now in Paris) to the  Boston Medical
 and SurgicaiJournal, for April 12th, 1854.
  Dr. Isaac Hays, in noticing the instrument of Helmholtz, remarks,
 that the intense light from it may, in some cases, prove injurious to the
retina, and he therefore urges great caution in its use.   In the "Adden-
dum" to his most excellent edition of Mr. Lawrence's  Treatise on the
 Eye, (1854) the reader may find further details upon this subject.
                          OVARIOTOMY.

   The fourth volume of the Transactions of the American Medical Asso-
 ciation contains by far the most complete table of all the known operations
 of ovariotomy, up to  1851, that has over been published.   It was com-
 piled Dr. Washington L. Atlee, of  Philadelphia,  whose own  extensive
 experience in this proceeding is so widely known.  Dr. A. has collected
 222  cases, being all that he could find recorded from 1701 to 1851.   Of
 these 222  cases,  52 were of the  minor section, 153  of  the major,  and
 17 unknown.  Of the  52  minor operations, 39 recovered, and*13 died
 or 1 in every 4, or 25 in 100.  Of the 153  major  operations, 95 recov-
 ered, and 58 died, or  1 in every 2 %, or 37, 91 in 100.   Of the 17 un-
 known sections, 12 recovered, and 5 died.   Of the  222 cases  146 re-
 covered,  and 76 died.  In 57 the operation was not completed, and in
 6  there  was no  tumor.  Of the 57 unfinished operations 24 were by
 the large section, 27 the small, and 6 unknown.   Of the 24 unfinished
 operations, 17 recovered, and 7 died.  Of the 27 unfinished minor sec-
 tions, 23 recovered  and 4 died.  Of the 6 unfinished unknown sections,
 5 recovered and 1diedL  Of the 57  unfinished operations, 45 recovered
 and 12 died.   In  25 of these 57 sections, it was merely exploratory, al
 of which recovered.   Of the  6, in which no tumor was found, 5 were
 major, and 1 minor;  3 of the former recovered, and 2 died ; the minor
 recovered, making 4 recoveries and 2 deaths.  In 27 cases, other im-
 portant diseases co-existed.  In 14, the uterus was diseased ; in 2, there
 was  procidentia uteri; in 1 hydrops  uteri;  in 1,  pregnancy •  n 1
anaemia; in 1, ascites and anasarca; in 1, obstructed bowel! • in 1 chronio
peritonitis; in 1, exhaustion before operation; in 1  imoe'ndW «Wfc  •
in 1  diseaseof the stomach; in 1, inflammation of the TucousScoa1  of
 he bowel; in 1  shattered constitution;  in 1, taberSuSSd™vTa2d
scirrhous mesenteric glands.
  In  83  cases, there were  adhesions ;  in 47  nonp •  in  Q9 ™f o*„+ a 
AMERICAN APPENDIX.
923
  Fourteen  died from peritonitis;  13,  from hemorrhage; 6, from ex-
haustion ; 2, shock of  operation ;  1, inflammation of mucous coat of
large intestine ; 1, gangrene of intestines ; 1, gangrene of  peritoneum;
1, peritonitis and gangrene ;  1, inflammation of lungs ; 1, peritonitis and
constitutional debility ;  1, ileus and phlebitis of lower limb ; 1, diarrhoea
and  peritonitis; 1, inflammation and gangrene of intestines ;  1, fibrous
tumor of the uterus resting  against incision ; 1, from venesection, under
a false alarm of peritonitis ;  1, bursting of hepatic abscess into the peri-
toneal  cavity ; 1, fall after  convalescence ; 1, inanition from irritable
stomach, in  consequence of pregnancy.   In 22 cases the cause of death
has not been particularly noted.
  One oatient died  in 70 days after operation ; 2, in 42 ;  1, in 30 ;  1,
in 21 ; 1, in 17 ; 1, in 15 ; 1, in 14; 1, in 12 ; 1, in 10 ; 1, in 9 ; 4, in
7 ;  7, in 6 ;  3, in 5 ;  1, in 4 ; 9, in 3 ; 4, in 2 ; 5, in 36 hours ; 1, in 32 ;
1, in 30 ; 1, in  17 ;  1, in 14 ; 2, in 12 ;  1, in 11;  1, in 8 ; 1, in 6 ;  1,
in 5 ;  1,  in  4;  2, immediately ; and in  19  it is not mentioned.   The
average time, in 57 cases was 7, 33 days.
  The character of  the disease, as stated in 120  cases, is as follows:
86  cystiform tumor  of the ovary ;  30, solid tumor;  10,  uterine tumor;
3, fibrous  tumor of uterus;  1, fleshy tubercle of uterus ;  1, fibrous tumor ;
7, solid tumor; 6, solid ovarian tumor; 1, cartilaginous and lardaceous ;
1, cartilaginous; 9, cysts with solid matter; 2. ovarian  tumor; 1, ova-
rian and uterine ; 1, fibrous cellular ; 1, lardaceous and cysts ; 1, pelvic
tumor ; 1, large sessile tumor; 1, several tumors ; 1, dense and vascular
cellular tumor ;  1, cysts and hydatids ;  l,hydadatid; 1, highly vascular
tumor; 1, pilous ovarium ; 1, cyst with bone hair &c ;  1, cysts with ex-
tra-uterine foetus ; l,cyst with bone, hair &c.; 1, cysts with extra-uterine
foetus ;  1, cysts of an abscess of ovary ;  1, omental tumor ; 1, conglom-
erated intestine ;  1, anomalous; and in 6, no tumor was found.
  Of the  86 cases of cystiform tumor, 57 recovered, and 29 died.   Of
the solid,  17 recovered, and 13 died.  Of the 27 complicated, 11 were
unfit for operation, leaving therefore 211  " legitimate " cases, of which
146  recovered, and 65 died.  Dr. Atlee claims 9 other cases as success-
ful, viz. that in which patient died from venesection, and others that died
from diseases not connected  with  the operation, the rate of mortality
being, from his estimate, 26j per cent.   This  is far more favorable than
that formed by Dr. Robert Lee in his Analysis of 162 cases of Ovarioto-
my, performed in Great Britain, {Med. Chir. Tran. vol. XXXIV.) for of
102 cases in which it  was completed, 42» terminated fatally, and in  60
in which  it  could not be finished, 19 proved fatal.
   In examining the  statistics of ovariotomy, we are struck with  the
very few  instances in which it has been resorted to by French surgeons.
                     PENIS, ANAPLASTY OF.
  We find in the British and Foreign Medico- Chirurgical Review, for
Jan. 1855, the notice of  an operation for restoring to the penis a cover-
ing, the skin having  been destroyed by disease.   It was performed by
M. Marchettiui, and was originally reported in the Gaz. Aled. Ital.—A
syphilitic ulcer had destroyed all the skin of the penis, and a consider-
able portion of that of the pubes;  the scrotum was entire.   The opera- 
924             NEW ELEMENTS OF OPERATIVE SURGERY.

tor pinched up a fold of the scrotum, passed a knife through the centre,
leaving the extremities attached, and then slipped  the penis through it.
Eight days afterwards, the skin was firmly adherent to the penis, which
was, however, bound down by its new  covering.  Two  incisions were
made through the scrotum, from the root to the end of the organ, by
which it became free, and cicatrization was complete in a few days.  In
May, 1840, we operated on a child laboring under a congenital  malfor-
mation of the penis, in which we were compelled to resort to anaplasty
for the removal  of the deformity.   The  penis  was imbedded in  an oval
depression in  the adipose substance covering the  pubis, and bore a strong
resemblance to the clitoris.  Throughout the whole length of its  inferior
border it was  united to the scrotum, the  surface of which was constantly
irritated  and  excoriated by the  urine, which  escaped  from a very small
opening close to the junction of the parts.  A small sound having been
introduced into  the urethra, and the penis elongated as much as possible,
I divided that portion  of the bridle beneath the apex, after which the
dissection was continued through  the skin and  cellular substance in a
semi-circular  direction on each side of  the penis, embracing about two
thirds of the  circumference of this organ.   Following  the urethra, the
lower border of which was necessarily exposed, I carefully cut in the
direction of the canal  for nearly an inch.   I next made  a transverse in-
cision through the integuments on each side of the penis for about three
quarters of an inch.   These commenced at the upper extremities of those
which had previously been made in a lateral direction, and the  portions
thus  detached were united by sutures in  the median line under the penis.
A small leaden tube was then introduced into tho urethra, and the penis
thrust into the finger of a glove of a suitable size, which  was fastened
around the body by means of tapes.  It was made still  more secure by
two  other tapes, which passed under  the perineum  and  around each
hip.   The junction of the detached integuments  in the median  line was
covered with plasters  and oiled silk,  to  exclude the  urine  from the
wound.   During the night the prepuce became greatly swollen, and tho
child suffered much  whilst discharging  its urine.  On the fourth day,
finding that the root of the penis was becoming somewhat strangulated,
the dressings  were removed, and pledgets  of lint smeared with  cerate
interposed between the penis and the scrotum.  Soon the swelling began
to subside ; the case proceeded in all respects most favorably, and at the
end  of a fortnight the whole was completely healed.   A report of this
case, with a wood cut, was published in  the American Journal of Med-
ical  Sciences  for April, 1847.

                        Penis, Rupture of.

   The following paper on this very rare accident, was read before the
New York Academy  of Medicine,  December 6, 1848, and afterwards
published in the  Transactions of the above society, Vol. 1 Part 1  1851.

Of Laceration of The Corpus Cavernosum  Penis, commonly called
   Fracture of  the Penis.  Illustrated by two cases.  By Valentine
   Mott, M. D.

   Among the lesions of important organs, I am not aware that there is
anvthiuir in the  standard works of surgery similar to those I propose  to 
AMERICAN APPENDIX.
925
relate in this paper.   The member to which they are confined is liable to
a great variety of serious and indeed formidable maladies and injuries,
with  which  all practitioners are more or less acquainted.   But few if
any have met with similar cases,  which induces me to lay them before
the public.
   My object therefore in relating them, is to have  them preserved, as
also to allay any great alarm that might be excited in the mind of  the
surgeon, and quiet the fear which is certain to be awakened  in the  pa-
tient.
   The affection to which I refer has been humorously  styled a fracture
of the Penis.  Thi3  is, however, a misnomer in  surgery, as there is in
the human  organ no bone  entering into its composition in  the normal
state.   In a strict surgical sense, no part  can be said to be fractured
which has not either bone or cartilage in its constitution.  The term rup-
ture or laceration is the proper epithet by which it should be designated.
The cases therefore ought to be termed a laceration of the corpus caver-
nosum of the penis.
   A. B., a  young man  living in Bergen, New Jersey, having been  re-
cently married, had his wife a day or two after this event leave him to
visit a parent who was  ill a few  miles distant, where she was detained
over night.   The  bridegroom, on rising from  his bed  in the morning,
found the penis in a vigorous state of distension.   In his haste to dress,
not being patient with this natural state of things, and without  giving
a reasonable time for its energy to abate,  he  struck it with considerable
violence  against tho bed-post.   At the  instant this was done, a noise
was heard of something breaking, and at  the  same moment a managea-
ble condition of the member followed.   On examination, as the bed-post
was found to be sound, he concluded that his own organ had suffered  the
injury.  He therefore alarmed the family, and it was soon reported that
he had fractured his penis.
  An extensive extravasation of  blood immediately followed the injury,
through the  entire penis, distending it to twice or more times its natural
size, changing it very quickly to a dark livid hue, and  presenting alto-
gether a most frightful and disgusting aspect.
  The greatest  imaginable  alarm was now excited in the mind of  the
patient  and  his  friends.  Professional aid was summoned immediately
from  the  neighborhood, and from the  novelty and urgency of the case,
further advice was sought from  this city.   Among others sent for was
the newly made  bride, who on being informed of  the nature of the frac-
ture, plaintively and innocently remarked, " that she was sure it never
would have  happened, if she had been at home."
  The tumefaction of the organ continued  to increase  for more than
twenty-four hours, until the  prepuce  rolled over the glans penis, as in
watery, urinous, and erysipelatous infiltrations of the filamentous tissue
of this part.
  Strict rest was enjoined in a recumbent posture.  General antiphlogis-
tic  treatment was pursued.   The penis was turned up over the pubes
and cold discutient lotions were  directed  to be constantly applied.   By
pursuing this plan of treatment, the extravasated  blood after a few days
began to be absorbed, and after a short time  was wholly  removed and
the member was restored to its normal condition and usefulness. 
926
NEW ELEMENTS  OF OPERATIVE SURGERY.
     B. C, a young and  healthy  man, about thirty-five years of age, un-
   married, fellow of the Academy of Medicine, camo under my notice on
   the morning of the 13th of May, 1848.
     In a very considerable state of alarm, he made the following statement
   to me.  That on rising from bed he found the penis in a state of full and
   vigorous erection,  and being somewhat in haste to dress, applied his
   hand on the left  side of the  member, and suddenly forced it into his
   drawers.   At the instant of doing it he heard a crack, as he  expressed
   it, and felt  something tear.  At the same time the penis began to enlarge,
   and in a few minutes was  distended to twice the size it  had in the state
   of a natural erection, and without the  hardness peculiar to this state.
   As he expressed it, his impression at the instant was, that he had, as he
   said, fractured it, as there was a stinging sensation of pain.
    Very soon after  I saw it, and the size was more than double that of  a
  natural erection, soft throughout, and of a dark purple color.  The ex-
  travasatcd blood reached completely to the extremity of  the prepuce, so
  that the merest point of the glans penis could be seen.   On turning it  a
  little to the right side  some  pain was felt at a point on  the left side of
  the  corpus  cavernosum, about  half an inch from the going off  of the
  scrotum, and it was there somewhat tender to the touch.
    From the statement of the patient, and the unseemly and frightful ap-
  pearance of the organ, there could be no doubt  that the left corpus cav-
  ernosum was lacerated.
    I advised  the doctor to  remain quiet  in a recumbent position, turn
  the penis up over  the pubes, and use a lotion of camphorated spirits.
  In the evening it had increased considerably in size, the regio pubis was
  also much tumefied, and the enlargement had extended over the left side
  of the scrotum.  Leeches were now spoken of;  but I feared they  mio-ht
  be followed  by erysipelatous inflammation and some of its fearful conse-
  quences.  I  therefore advised that a bladder partly filled with pounded
 ice should be applied constantly over all the affected  parts durino- the
 night, and the penis  to be turned up over the abdomen.  This was cheer-
 fully and  promptly  done.  The object in view was  to  promote the ab-
 sorption of the extravasated blood, and more particularly  to prevent any
 erection from taking place during the night, by which the extravasation
 would be greatly increased.   During the night,  however, while asleep,
 the bladder was displaced and a partial erection took  place, which was
 accompanied  with severe pain at the injured part, and an apparent in-
 crease of the extravasated blood.   It instantly awoke the  patient,  when
 he reapplied  the ice, with immediate relief.
 • iT1iieueXida? tl?° ffeneral  tumcfaction of the penis had  a little dimin-
 ished,  but the dark blue color was considerably increased.  It was now
 also apparent over the entire swelling of the scrotum.
   He was desired to persevere in the same treatment.
   On the following day the enlargement of the penis had evidently les-
 sened,  and the color  6f all the extravasated parts was of a still darker
 nl6;^    t  lnte«urne"ts of thc whole reSio  Pubis began to show a livid
 aspect.   It was now that upon passing the finger along the left side about
 halt an inch from the scrotum, the point of lesion could be discovered.
   Ihe  doctor now felt well enough to visit a few patients, and rode out
in his carriage.  He carefully preserved the penis turned up, and  from 
AMERICAN APPENDIX.
927
 time to time wet a cloth with camphorated spirits and applied it over all
 the parts.
   The swelling  continued to diminish daily, and the patient gradually
 resumed his accustomed occupation.  The whole of the  parts  involved
 in the extravasation, the entire penis, nearly all the scrotum, part of the
 perineum, and the regio pubis, to the extent of more than three inches
 from the  penis,  making a semicircle to the groins, presented  from its
 dark color, a novel  and  unique  appearance, such as I never witnessed
 before in any case.
   On the 10th of May from the accident, the swelling of the penis, scro-
 tum, and pubes had in a great measure subsided, but there was still some
 considerable  discoloration, particularly of the  scrotum.  The patient
 states that the erections are yet  attended with  considerable pain, and
 that the penis is  curved a little to the side opposite fhe injury.   To the
 feel as well as sight, there is a considerable thickening to the extent of
 an inch in length by measure, of  the corpus cavernosura, and it extends
 from the centre of the dorsum to the corpus spongiosum, very similar to
 what a tendo achillis presents after being lacerated.-
   June 5—Twenty-third day from the accident.   The doctor informs me
 that all pain has  left him, and that the extravasation has entirely disap-
 peared, that the  incurvation to the opposite side has in a great measure
 passed away,  and that the  hardness  is  considerably  lessened.  In a
 word, that this organ has nearly  returned to its normal condition.

   New York, June  5,1848.

  July 1.  All irregularity has mostly  disappeared, and the organ may
be said to have resumed its normal state.
   October, 1850.  Since the above was written, I have met with several
recorded cases, in the  periodical  Journals, of this injury, and had one
case related to me by a professional  friend  which was  occasioned  by
masturbation.
              PERICARDIUM, PARACENTESIS OF.

   There is  reason to believe  that the first successful operation of this
nature was performed by Dr. John C. Warren, of Boston.  M.  Velpeau
has referred in the text,  to this case, and has expressed the opinion that
it is the only one worthy of entire credit.  On this account, we hesitate
not the reader, with what to present M. Velpeau has omitted, the details of
this operation, which we find  in the second edition of Henry H. Smith's
Operative Surgery, vol. II. p.  62.   The patient, a female, set. 35, suffered
considerably from palpitation  and dyspnoea, and  other consequences of
hydrops pericardii.  An  incision being made on the face of the seventh
rib, the integuments were drawn upwards to the sixth intercostal space
and the tumor or prominence,  which was  very marked, carefully  punc-
tured with  a small trocar and  canula,  the pericardium beino- easily
reached.   Between five and six ounces of serum being thus  evacuated
the wound  was carefully closed, the chest bandaged, and the patient 
 928             NEW ELEMENTS OF  OPERATIVE SURGERY.

 recovered sufficiently in a few weeks to leave the Massachusetts General
 Hospital, but was not heard of subsequently.
   M. Trousseau has reported another case in the Archives Generates de
 Medicine, for Nov. 1854.  We quote from the Brit. For. Aled. Chir. Rev.
 for January, 1855, Am. ed.,  p. 208.   A man aet. 61, had  severe  frontal
 headache, lassitude and praocordial pain.  There was intense dyspnoea, a
 little cough, a very quick pulse, prominence in the cardiac region, in-
 creased percussion dullness  at the same point, extending to the  second
 rib and to the right of the sternum ;  the heart's sounds were feeble  and
 distant.  For a month the effusion remained the same ; only once, for two
 days, did it seem to diminish, and then there was a little  friction  at the
 base.  Afterwards, the dyspnoea  increased  and the fluid augmented, as
 the dullness reached to the clavicle.   There was also  pleuritic  effusion.
 An  incision was made in the  fifth  intercostal  space  one inch  and  a
 quarter from the sternum.  Thirteen ounces of fluid slowly escaped, the
 cardiac dullness  decreased in extent, and the respiratory murmur  could
 be heard as low as the fourth  rib.   A day or two afterwards the pleuritic
 effusion was  found to have  increased, the  heart  was displaced to the
 right.   Thoracentesis was practised in the sixth space in the axillary line,
 and although at first the canula  was blocked up by false membrane, even-
 tually sixteen  ounces  were removed.  Neither  pleural nor pericardiac
 effusion reappeared, but, soon after, signs of tuberculosis of the  left lung
 came on.
  Mr. Walshe, in his work on Cancer, relates a case in which Mr. Schuh
 introduced the trocar and  canula in the  fourth  intercostal space, or
 between the fourth and fifth ribs, and drew upwards of a pint of reddish
 serum, which flowed in gushes  corresponding with the systole of the heart.
 Great relief followed the operation, but six months afterwards, the patient
 died of  an encephaloid growth  near  the trachea.   The autopsy  allowed
that the pericardium had been punctured, and it was found adhering to
the heart by thick cellular tissue.
                       POLYPUS, AURAL.

  The best instrument, says Mr. Wilde, for the removal of aural polypus
from any portion of the meatus, is the small snare-like apparatus repre-
sented in the following figure.
<TT^
  It consists of a fine steel stem, five inches in length, and bent in the
centre, so as not to interfere with the direct sun-rays.   There is a mov-
able bar sliding on the square portion near  the handle, the latter part 
AMERICAN APPENDIX.
929
 fitting over the thumb as shown in the cut.   The upper extremity is
 perforated with holes running parallel with the stem ;  and loops at the
 angle  serve for the same purpose.  A fine wire, fastened to the cross
 bar, passes through these loops and holes ;  it should be of such a length
 that, when the cross bar  is drawn up tight to the handle, the  ligature is
 fully on the stretch.  In using the instrument the cross bar is pushed for-
 ward, and a  noose made of the wire at the  small extremity, of sufficient
 size to include the morbid growth, which it is then made  to surround, and
 towards  the  root  of which it is pressed by means of the stem.  The
 cross bar is then drawn firmly to the handle, while the  point of the  stem
 is pressed downwards, effectually cutting  across  or  drawing with it
 whatever is included  in the noose.  The point of  attachment, or other
 portion not accessible to the instrument, must be touched with the armed
porte-caustic.   ( Wilde's Pract. Obs. on Aur. Surgery,  pp. 397-8.)
                             RANULA.

   Dr Borelli has reported in the Gazette des Hopitaux, Feb. 4th, 1854,
 three cases of ranula successfully treated by injection with an alcoholic
 tincture  of iodine.   The  cysts were punctured by a lancet, and  then
 filled with the tincture of iodine, of which a part was allowed to remain.
 This was followed by severe pain, which lasted for some hours.   On the
 next day there was a moderate amount  of  inflammatory  swelling, but
 the symptoms subsided  and the cure  was complete by the twelfth  day,
 the mucous membrane presenting its normal color and appearance.
   Mr. Skey is an advocate for the use of the sefton in this  affection, and
 relates a case  of enormous size, successfully treated in this manner.
 The tongue was forced back against the  soft palate, she could not swal-
 low without a great  and painful  effort, and even her respiration was af-
 fected.   It had the  appearance  of a large tumor occupying the  mouth,
 of which the walls were  firm and  thick.  I introduced a single coarse
 thread of silk through it, and in a week it was reduced nearly one-third
 in size, and then another, and so on, till, at the expiration  of six weeks,
 scarce a vestige of the disease  remained.  (Operative Surgery, Lond.
 Ed. p. 433.)
   Mr. Fergusson prefers the extirpation of the cyst, should puncture
 and emptying the sac, or excision of a portion of the  latter fail.   This
 proceeding he considers  far superior to any others, especially the se-
 ton or caustic.  He   encountered a case  which gave him great deal of
 trouble in its extraction, a sketch of which is  given in his Practical
 Surgery, 4th Amer.  ed., p. 445.  After perusing the details of this ope-
ration, we must  confess, should a similar case come under our own care
we should feel inclined first to try the seton, which succeeded so admi-
rably in  the instance  reported by Mr. Skey.   In many  of these  cases,
doubtless, a sufficient degree of inflammation to obliterate the sac might be'
induced, by touching  its interior with a camel's  hair brush dipped in Tinct-
ure of Iodine.
  Vol. III.                    117 
930
NEW ELEMENTS OF  OPERATIVE SURGERY.
                        .RECTOPLASTY.

  M. Demarquay has performed the following anaplastic operation, after
the extirpation  of a cancer of the rectum.   Having dissected  up the
healthy edge  of the bowel, he drew it down so as to occupy the place
of the lower part which had been removed.   The bowel was then united
to the skin at tho margin of the anus.   We are informed that a yielding
cicatrix was the  result, and that the function of the part was quite ro
stored.   (Bull.  Gen. de  Ther. torn, xlvi., p. 41; also. Brit. For. Med.
Chir. Rev. July  1854, p. 198).
  Excision of the rectum for carcinoma is not a favorite operation either
with British or  American  surgeons.  If, as Mr. Quain remarks, in his
valuable treatise  on the  Diseases of the  Rectum, (1st  ed. p. 261,) the
disease  should be strictly limited to a small  space in the lower  end of
the  gut, the removal might be effected  with a fair prospect of advantage,
" but otherwise it is wholly  inadmissible.   Perhaps the operation of M.
Demarquay might be performed after excision, in such cases as those to
which Mr. Quain has referred with benefit to the patient

                        Rectum, Abscess of.

  A remarkable case of this affection  has  recently been  treated by
Dr. Sayre of this city, a report of which was published in the New-York
Journal of Medicine, for March, 1854.   The  patient, a prorauient clergy-
man, was supposed to be  dying from what was  called " neuralgia of the
rectum."  Indeed, when  first  seen  by Dr. Sayre, he was  nearly in a
moribund state.  The true  cause of his suffering having been detected,
the  patient was placed under such treatment as should best prepare him
to undergo an operation for a radical cure.  The edges of an old, hard,
and  well defined ulcer, could be felt just below  the upper edge  of the
superior sphincter, and in the posterior aspect of the intestine, & The glu-
tei muscles on  either side were distended to their utmost, and an explor-
ing needle plunged into the most prominent portion, passed two  and a
quarter inches before its point  became free.  Gas, of a most offensive
order escaped  from these punctures, and the patient was  materially re-
lieved.  A free incision was also made in the situation of the first  punc-
ture, and  more  than a quart of fasces and matter escaped.  A  probe
passed  readily into the rectum,  and swept over a largo  surface  under
the glutei muscles.   Some ten days afterwards  the following operation
was performed :                                             r
  " The patient  was  laid upon his side and face, with his limbs  slightly
flexed, and nates exposed to a good light, when a probe was passed, from
the right external opening four inches  from the anus, three  inches and
a half before it reached the ulcer in the  intestine.  With a  long probe-
pointed bistoury pushed down upon  the finger  in the rectum,  a single
cut sufficed to lay the parts freely open.  The parts  divided  were  firm,
almost cartilaginous, from long-continued inflammation.  There was not
much hemorrhage, but still  the patient sank considerably, and  required
very free use of  brandy.  After  some  few  minutes, however, he  rallied,
the pulse became stronger, and it was  thought by those present that  he 
AMERICAN APPENDIX.
931
 would be able to bear the incision upon the oposite side.  Not having a
 probe-pointed bistoury of sufficient  length to reach  from the  external
 opening into the rectum, which  was  nearly  six  inches, I took  a long
 straight-pointed  knife, and  passed it down upon my finger into the rec-
 tum, and made a rapid  incision through all that portion of the gluteus
 maximus muscle included  between it and  the anus.   The hemorrhage
 was  considerable, but readily checked by ice and pressure, only one
 ligature being required.
   The patient bore the  operation with the  most  heroic fortitude, never
 uttering a groan or  complaint, and at its  completion expressed  great
 delight that it was over, and immediately rolled upon his back, and swoon-
 ed.   His mouth fell open, the surface became pale, the pulse ceased at the
 wrist and elbow, and the heart was scarcely audible, respiration ceased
 entirely, and in fact he was to all appearances dead.  Immediate resort
 was had to artificial stimuli, as mustard and hot  water externally, and
 brandy and ammonia was attempted to be  administered internally ; but
 finding him unable to  swallow, artificial respiration was immediately re-
 sorted to, and it  became necessary to continue it for some minutes before
 respiration took place, after which brandy and ammonia were administer-
 ed, ad libitum, until complete reaction ensued, which occupied nearly an
 hour and a half from the operation,  during which  time he drank over a
 pint of brandy, and nearly a half ounce of aqua ammonias.
   The cavern, which was considerably larger than the head  of a foetus
 at the sixth mouth, and  lined with bkck, ragged, fetid sloughs, was then
 filled with lint, saturated in Le Doyen's disinfecting  fluid, and covered
 with ice to prevent hemorrhage.  I administered 15 drops of Magendie's
 solution, and left directions for him to take brandy and beef-soup every
 hour.  In the evening I  found him tolerably comfortable, pulse 110, but
 quite firm and regular ; had had three hours of refreshing sleep  since the
 operation, but was unable to evacuate his bladder, which was emptied by
 the introduction of the catheter, which operation was repeated about 12
 o'clock at night.
  August 17, 6 a.m.—Introduced the catheter and evacuated the bladder,
 which had not yet recovered its contractile power, and required pressure
 over the abdomen in oroTer to  make the urine flow.   In all other respects
 as comfortable as could  be expected.
  1 p. M.—After again drawing off  his water by the introduction of tho
 catheter, with the assistance  of Dr. Thebaud and Mr. Bartholf  I re-
 moved the lint from the wound, which was excessively  offensive and
 made a more careful examination of the cavern than had been done the
 day before.
  The coccyx had  sloughed from the  sacrum, and two of thecoccvgeal
 bones were found loose in the wound ; the fingers could readily  pass un-
 der the swollen integuments on the posterior aspect of the sacrum nearlv
 as high up as its junction with the lumbar vertebras.  In order to relievo
 the tension over the sacrum, a third incision was deemed necessarv and
 made between the two others,  nearly parallel to the sacrum,  and about
 two inches in extent; the sacrum was not denuded of its oeriosteum p,
 cept at its coccigeal extremity, which was readily felt  to be exposed bv
 the probe or finger-nail   The sacro-ischiatic ligaments of the left side
were exposed and partially sloughed, hanging with ragged shreds   The 
932
NEW ELEMENTS  OF OPERATIVE SURGERY.
fat in the recto-ischial fossae of either side had been entirely destroyed,
leaving a cavern which would readily receive the two fists of an ordina-
ry-sized adult; the tuber ischii of either side were exposed, but not de-
nuded of their periosteum ; just external to the tuber ischii of the left
side, deep under the muscles, a sinus was discovered running in a curved
direction 6 3-4 inches to a point just back of the scrotum,  and, by ele-
vating the limb, gave exit to  about a wine-glass  of pure healthy^ pus.
The upper border of the ulcer, which had  been the commencing-point of
all the difficulty, was thick,  hard, and white; the lower  and back  por-
tions between the incisions  had sloughed away ; the whole cavern was
of a greenish black  color, and excessively  fetid; the walls of the abscess
were from an inch to two inches in thickness.
   After washing out the intestines by an injection, the abscess was care-
fully injected with Labarraque's solution, and dressed with lint saturated
with Le Doyne's disinfecting fluid and  tinct.  myrrh, and covered with a
yeast poultice.  The dressings were changed and the catheter introduced
every six hours for the succeeding four days, after which he was enabled
to evacuate his bladder without assistance.
   The discharge was very copious and offensive, and at each dressing a
large amount of sloughing shreds was washed off  by the  injection.   He
was fed upon the most generous diet, and brandy and  quinine were ad-
ministered liberally.   In  about ten days from the  operation, the wound
had assumed a healthy aspect, and granulations were  abundant, partic
ularly from the deepest part of the abscess, around the edges of the ul-
cer, where the  growth was  so rapid as almost to assume a  fungous ap-
pearance, and for some time I  hesitated about the propriety of its remo-
val, fearing that it might be malignant, as the patient had  lost two sis-
ters by  cancerous disease.
 
AMERICAN APPENDIX.
933
    But, by the advice of Dr. Dupierris, a distinguished and accomplished
  surgeon of Havana, I was induced to let it remain, as he stated that he
  believed, in so deep and large an abscess, the central part would grow
  up more rapidly than the rest, and act as a sort of pillar or central brace
  to which the sides could be afterwards attached by paring the edges and
  bringing them together.   This was a new.idea to me, but I am frank to
  confess, from the result in this case, it seems to be practicable.
    The above drawing, by  Mr.  Rennie, was made four weeks after the
  operation, when  the  wound was reduced  more  than one-third by the
  abundant granulations which were forming in it, and, with the exception
  of the deep and narrow  sinus upon the left side, which extended down
  as far as the scrotum, everything was healthy; this was  injected  with
  iodine without  any benefit, and I then wished  to draw a  lead  seton
  through it, but was unable, as the probe came down against the ramus of
  the ischium and pubis.   I therefore covered the probe about  six inches,
  by melting upon it nitrate  of silver, and then  passed it into the sinus,
  and  left it until  the caustic was dissolved.  This fortunately excited a
  healthy  inflammation  and closed  the sinus, and  on the 1st of October,
  with the assistance of Dr. Thebaud, I pared off the  edges of the wounds,
  and also the fungous central tumor of its mucous covering, and brought
  the edges together by two straight ordinary darning needles and a twisted
  suture, one needle on either side, and dressed with adhesive straps and
  pressure.
    On one side union took place by first intention, of the whole wound,
  and on the other to a considerable  extent; but  finding it too close to
 admit of free flexion of the  body, and also obstructing the passage from
 his bowels, I was  compelled to  destroy the adhesions on one side, and
 allow it to  granulate from the bottom with a much wider  cicatrix.   A
 large bougie was introduced  into the rectum daily, and retained some
 minutes in   order  to prevent  too  much closure  of its orifice, and the
 wound dressed with lint spread with Turner's cerate.
   On the 1st of November the parts  had entirely  healed, leaving  him
 perfect control of his anus, by some sort of artificial sphincter, and Dr.
 B. left for the country for  recreation, his general health being much
 better than for some years previous.   An issue which I had  established
 in his arm about six weeks previous was discharging freely, and I have
 given  him  directions to  continue  with it  through life.  Having  had
 asthma and  slight cough  for some  years, together  with repeated hem-
 orrhages  from the bowels, and this being  the  third time he had been
 operated upon for fistula within ten years, and as nature seemed deter-
 mined to have some drain, I  therefore  placed it in  his arm."
   The patient is now in excellent health, and is able  to discharge  his
 pastoral duties.                                              G
   Mr. Quain   in his valuable  treatise on  the Diseases of the Rectum
 lately published, p. 84,  relates a case in many respects similar to  the
 above, with the exception that it proved fatal.  In this case, with the ex
 tensive  abscess in the vicinity of the rectum, there were also tubercular
 disease  of both lungs, and  hemorrhoids which had long  been standing
At page 81, Mr. Quain reports  another case of fistula in ano and pelvfc
abscess  in a person who had previously had indications of phthisis   An 
934            NEW ELEMENTS OF  OPERATIVE SURGERY.
operation was performed, which was followed by a complete restoration
to health.  In Dr. Sayre's  patient, there were symptoms of pulmonary
disease, but these have disappeared.  We might refer to other instances
which  form an exception,  to the  rule  inculcated  by  Mr. Curling, viz.
that "  in phthisical patients no judicious surgeon ever ventures to use
the knife."  (Diseases of the* Rectum, p. 74.)
  Some three years since, we were consulted as to tho propriety of an
operation in a case of fistula in ano, the patient being affected with an
harrassing cough.  The latter was most severe whenever the discharge
from the fistula was most  profuse.  The fistula was successfully treated
by caustic injections, and all pulmonary symptoms have disappeared.
              SEPTUM NASI, HYPERTROPHY OF.

  MM. Brulet and Heylen have reported some remarkable cases of this
somewhat rare affection in which the deformity, arising from the obliqui-
ty and increased length of the cartilages of the septum nasi, was remov-
ed by resection of  a portion of the cartilage.  M. Brulet proceeded as
follows :  the inferior part of the septum was separated with scissors even
unto its junction with the upper lip.   The hypertrophied part  was then
removed with a tenotome, and with a single  suture  union was rendered
eo complete that no trace of the operation could be perceived.   In resect-
ing the  projecting portion of the septum, M. Heylen made an incision
on the right side of the  cartilage (the tumor being in the right nostril)
which allowed the  mucous membrane covering the  projecting  part to be 
AMERICAN APPENDIX.
935
dissected from both sides, and separated with the scissors.  The resec-
tion of the cartilage was attended with no difficulty, but the thinness of
the mucous membrane opposed the reunion of the edges of the wound,
and it became necessary to introduce the end of a small sound, protect-
ed with agglutinative bandages, into the right nostril, to keep the septum
in place during the cicatrization.  Three days  after the  operation  the
obliquity of the septum  was no longer perceptible externally, and in
nine days the cure was complete.   M. Heylen remarks  that the fear of
making a cicatrix under the septum of the nose, and thereby increasing
the obliquity, induced him to choose this mode of operating, though he
believes there would be no risk of obtaining union by first  intention in
making an incision of the septum  laterally, in dissecting  the cartilage
from both sides, separating the parts, and then uniting the wound.  (Ran-
kin's Abstract, Vol. 5 ; or Am. Journ. Med. Sciences, Oct. 1847, p. 490.)
                        SPECULUM, ORIS.

  Dr. Smith, a dentist of Edinburgh, has  given, in the  Monthly  Jour-
nal for April, 1854, a description  of a  speculum adapted for employ-
ment during operations on the mouth, under chloroform.
  It consists of three parts :  viz. the larger steel portion, intended for
holding back the edges of the lips, and keeping the jaws widely separate,
on one side of the mouth, 2.  An elastic band, attached by one extremi-
ty to this, and intended to be passed round behind  the  patient's  neck,
and  brought to the other side of the mouth, where, the flat  hook is at-
tached to it, and serves at once to keep the lips  back at this  side, and
the whole  instrument in its  place.   The same size, of course, will not
answer for the adult and children.
                          SPINA BIFIDA.

  Rokitansky remarks,  that " when the nerves and  spinal cord  are
not involved in the  disease, this affection is capable  of cure  like the
dropsical sacs of the cerebral arachnoid, by being gradually emptied or
by ligature. (Pathological Anatomy, Syd. Ed. Vol. III., p 438 )   Ho
states further, that a congenital dropsy of the arachnoid sac sometimes 
936
NEW ELEMENTS OF  OPERATIVE SURGERY.
 occurs, which is closely allied to spina bifida, and in which, whilst the
 sac is uniformly dilated, the vertebral canal maintains its integrity.
   Mr. Prescott  Hewett, of St. George's Hospital, has  published some
 very interesting cases of spina bifida, with remarks, in the Lond. Med.
 Gazette, Vol. XXXIV., 1844.  In  this report he refers to the impor-
 tance of a knowledge of the connection which generally exists between
 the chord or the nerves and the walls of the sac.   Although cases have
 been  observed in which these parts had no connection with the sac, yet
 in by far the greater number, the nerves  have been found to be in some
 way thus connected.   Of twenty preparations of spina bifida, occupying
 the lurabo-sacral region, which Mr. Hewett has examined, he found but
 one in which the nerves were not connected with the sac.   In puncturing
 the tumor, the mesial line should be avoided,  especially in the  sacral re-
 gion, for it is generally at this part, that the cord and its nerves are con-
 nected  with the sac;  and by puncturing at one side of the sac, the risk
 of wounding any of the nervous branches is diminished.   Again, Mr. II.
 gives  the  preference to a grooved needle or a small trocar, as, if a lan-
 cet be used, some important portion of the contents of  the  sac may be
 wounded.  The following case with the remarks appended, was reported
 by Dr. Townsend in the last edition of this work:
  A perfect cure of a case of spina bifida in a child aged about nine years,
 was effected at least fifteen years since by Dr. Mott, by means of the en-
 tire exsection of the tumor which was near the size of a goose egg, and
 which had existed from birth over the lower part of the dorsal  vertebrse.
 The integuments and sac had become very much thickened, so as to have
 even a normal appearance.   An elliptical incision was made on each side
 of the tumor, in order to leave integument enough to be approximated
 over the  deficiency in the vertebrae.  The wound was  then treated by
 interrupted  sutures in the  manner of hare lip.  It healed perfectly by
 the first intention, and the child was completely cured and  afterwards
 enjoyed vigorous health.   It will be  seen, therefore, that this process
 lately successfully revived, (see notes in the text of this volume towards
 the conclusion,,)  was certainly employed in this country, and with the
 most happy result, by  Dr. Mott, as far back as the  year  1830.   A case,
 we  perceive by the  Gaz.  Medicate, has very recently been cured in
 Fiance by excision  of the  tumor, and then uniting by a sort of quilled
 suture.
   Conservative surgery will owe much to M.  Dubourg, physician of the
 hospital of Marmand, (France,) if the two remarkable and radical cures
 of spina bifida effected by him should establish the new pathological
 views he has suggested in  respect to this  hitherto  formidable affection,
 and upon which his  successful treatment was  based.   M. Dubourg con-
ceived, very naturally, that the superincumbent soft tissues  would have
much  to do with the approximation of the boney edges of the congenital
 deficiency in the spine; and no doubt, recollecting the flexible gelatinous
character of the boney tissue in early infancy, to which  period of  life
this congenital disease belongs, considered that the soft tissues might be
employed to modify or complete  this  approximation, as  they frequently
do in cases of hare-lip.   Accordingly, in two infants, one only  8 and the
other 11 days old, M. Dubourg, after making an elliptical incision at the 
AMERICAN APPENDIX.
937
base of the tumor in the lumbar region, and  which tumor in each case
was pediculated and about the size of an apple, with its duct placed on
and communicating with the spiral marrow at the hiatus where the pro-
cesses and body of the vertebras  were wanting, removed  the tumor in
each case, by which means an opening was made into  the  spinal  canal,
and a very large quantity of the serosity of the same, of a reddish color,
discharged.   After this, the lips of the wound were immediatetly brought
firmly together by four pins and  strong-twisted sutures applisd  around
them, the points of the pins  being separated  from the integuments by
small compresses, and the whole sustained by strips of adhesive plaster
and a body bandage.   In four days the pins and sutures were removed,
the strips of plaster only being left on the parts.  In fifteen  days, the
cure  was  complete, presenting a strong rose-colored cicatrix,  forming
over the spinal opening a solid protection.  (See Gazette  Medicate de
Paris, 1841;  and Journ. des  Connaiss., <fec, de Paris, October, 1841, p.
168-169.)  T.]
   Dr. Mott has cured another case in which  the affection  was seated in
the lower part of the cervical, and upper dorsal vertebras.  The child was
9 days old.  The tumor was globular, about l£ inches in diameter, and at-
tached by a narrow pedicle, half an  inch in diameter, between the spin-
ous processes. In extirpating the tumor,  a communication about the size
of a crow-quill, was found leading into the cavity of the spinal marrow;
an elliptical incision was made on each side of the tumor into the sound
portion of  the integuments, and the  mass extirpated at its root.  The
lips  of the wound were closed, as in  hare-lip, by two  interrupted
sutures, aided by  adhesive plaster.   The plaster was renewed twice in
the course  of  ten days, at the expiration of which period the wound  was
perfectly healed.
   In the Gazette Medicate de Paris for April, 1854, p. 220, there is the
report of a case of spina-bifida which  M. Chassaignac cured by means
of iodine  injections.   The injection  was composed of equal parts of
water and of tincture of iodine.   In  the course of a few hours alarming
convulsions supervened, but  these soon subsided  and the patient  was
cured.  M. Pichaud has, also, reported a case in the Bull, de  Ther.
Aled. et Chir., Feb. 15, 1854, successfully treated on the  same plan.
In another case treated by M. Velpeau, no unpleasant accident followed.
Dr. Brainard  of Chicago, has operated in the same  manner, but of his
success we are not aware.
   Dr. Sayre of this city, has kindly furnished us with the particulars of
two very interesting cases which  he has cured by excision, but our limited
space prevents us from inserting them in detail.  In one of  these the
tumor  was  strangulated by  means of a ligature before it was excised
and Dr. S. is inclined to believe  that his success  was owino- to the fact
that all communication with  the spinal column was thus cut off, and the
wound made to heal close to  the opening,  and supply  the place of the
bony arch.
   We  have recently  treated a case  by a  combination of the wire liga-
ture and puncture.  The wire was gradually tightened from  day to day
and the tension relieved by  the oozing from the punctures.   Matters'
progressed favorably until the fourteenth day, when the child, 15 months
old, was killed by an overdose of laudanum  administered by  mistake
The operative proceedings in this case did not give rise to convulsions
in a single instance. 
938
NEW ELEMENTS OF  OPERATIVE SURGERY.
                        SPONGIO-PILINE.

  This  name has been  given  to  a substance invented and patented by
Mr.  Mark wick, as a subsitute for the poultices  and fomentations usually
employed to impart  moisture, warmth or cold, to an  inflamed surface.
It is composed of wool and sponge felted together, and then rendered
impermeable at the back  by means of a coating of Indian rubber.   It
retains  for many hours the qualities of warmth  and moisture, and pre-
vious to its application all  that is required is, to soak it well in hot water,
then press out the fluid, and confine the moist  spongy  surface, as hot as
the patient can bear it, closely on the part affected, by means of a common
roller bandage or a handkerchief.   It is said to be much more agreeable
to the feelings of the patient than tho poultice, and is incomparably its
superior as regards neatness.  In England, its effects  have been highly
praised  by some of the most eminent practitioners.   Mr. Markwick also
makes  an elegant soft water-proof woollen  fabric, which he calls Im-
permeable Piline, which may be cut into knee  or shoulder straps, chest
protectors, anklets, lumbago bands, socks, gloves, and many other forms.
                          STRABISMUS.

  A diversity of opinion seems to prevail at the  present day, as to the
value of the division of the recti muscles in cure  of strabismus.   From
an improper selection of cases, badly performed operations, &c, &c., fre-
quent failures have  occurred, and in some instances an absolute injury
has been done to the patient.   In the opinion of Prof. Syme, the true
sources of the  obloquy which this operation has incurred, are the igno-
rance and want of  skill on the part of the operators, and he further be-
lieves that it is deserving of the greatest confidence. (Month. Jour. Med.
Science, April,  1853.)   Dr. Isaac Hays, of Philadelphia, whose  author-
ity in all matters pertaining to ophthalmic surgery cannot be questioned,
thus expresses his views upon this subject, in  the last edition (1854)  of
Mr. Lawrence's Treatise on the Diseases of the Eye, pp. 899—900 :
  " In  cases, however, judiciously selected,  and  when the operation is
skillfully performed, entirely satisfactory success has been attained, and
this operation must now be considered as an established surgical means
for the relief of certain forms of strabismus.  Mr. Walton, in his recent
work, expresses a similar  opinion.  He states that this operation is a
singularly successful one, ' equaling in its permanent effects that of any
other operation, and surpassing most  of those which  are  practised for
the  removal of  deformity.' "
  " A relapse has never occurred in our practice, and Mr. Walton makes
the same statement.  We have little doubt but that in the supposed re-
lapses the muscle had never been  thoroughly  divided,  and the operation
therefore  incomplete.  Thirteen  years have now  elapsed since our first
operation, and we believe the first in this country, was performed,  (23d
of August  1840,) and  the cure  has  continued permanent; and this is
also true, so far as we can ascertain, in regard to  all the cases in which
we have operated." 
AMERICAN APPENDIX.
939
  Mr. Walton agrees with Prof. Syme, in attributing the failures of the
operation to the operator, who  does  not, in  such instances, completely
divide the muscle.
  " A long and familiar acquaintance with the subject has convinced me,
that to the operator is to be attributed the odium of failure in most of the
unsuccessful cases occurring in  early life.  I have myself operated  a se-
cond  time on cases that have passed under the hands of other surgeons ;
in all I have succeeded—the second attempt being undertaken  in  each
instance  on account of the abducting power being defective.
  Over and over I have seen patients that have been  operated on dis-
missed under the  supposition  that  it  was impossible  to put their eyes
right, when I have been certain that the internal rectus muscle had not
been  divided.   That there is a greater liability to take up a portion only
of the muscle than is supposed, any one may convince himself by oper-
ating on  the dead subject, when we will find that, unless there be  great
precision, this error will  be apt to occur."  (Operative  Ophthalmic
Surgery, Am. Ed. 1853, p.  265.)
  It will hardly be credited that the hemorrhage after this operation can
ever be serious, yet Mr. Lane, of London, in one instance was compelled
to resort to transfusion to save a boy whose life from  this cause was in
imminent danger.   This patient was of a hemorrhagic diathesis, and his
life had several times before been in great  danger from slight injuries.
This  case is reported in the London Lancet, No. 896, p. 185.
                STRICTURE OF THE URETHRA.

  Since the publication of Professor Syme's treatise on  " Strictures of
the  Urethra," in 1849, the treatment of these affections by external in-
cisions has been  much discussed.   The doctrine  previously inculcated
was, that whenever an instrument could be passed into  the bladder, no
external  incision could be necessary; but  Prof. S. would  reverse this
maxim and make permeability an indispensable pre-requisite to the per-
formance of this  operation.  He recommends this proceeding in cases
" where the contracted canal is  so extremely irritable  that the introduc-
tion of an  instrument aggravates the symptoms, and exposes the patient
to various  dangers from the local and general disturbance thus excited.
In the other, the peculiarity consists in a contractile tendency so strong
as quickly  to counteract the effect of dilatation, and thus render it use-
less."  A  grooved director, slightly curved, and small  enough to pass
readily through the stricture,  is introduced and confided  to an assistant.
An incision is then made in the middle  line of tho perineum, or penis'
or wherever the stricture  is seated.  This  incision should be about an
inch, or  inch and a half in length, and extend through the integuments
and subjacent  textures exterior to the urethra.   The director having
been reached, the  point of the knife  is passed  into the groove behind
or on the bladder side of the stricture.  The knife is then run forwards
so as to  divide the whole of the thickened  texture at the  contracted
part of the canal,  when the director may be withdrawn.  A No  7 or 8
silver catheter is then passed  into the bladder, and retained by means 
940
NEW ELEMENTS OF OPERATIVE SURGERY.
 of tapes.   A plug should be inserted to prevent  trouble from the dis-
 charge  of urine.  The patient  is to  keep quiet in bed for 48  hours,
 " when  the catheter should be withdrawn and all restraint  removed."
 pp. 41-2.   According to Mr. Henry Thompson's Jacksonian Prize Essay
 (1852)  on strictures of the urethra, the operation at that time, had been
 performed in 115 or 120 cases, (p. 257) only four of which proved fatal.
 There was a striking similarity in the characters of the lesions observed
 in these four cases, the cause of  death, having been in all, pyohoemia.
   To the  question how far the operation is entitled to be considered a
 means of cure, Mr. Thompson, after  stating that a larger experience is
 required to answer  this question  fully, remarks, p. 265, that the cases
 collected show there  are three results which may follow:—
   " It may fail to afford any relief.
   It  may cure for a  short period, and afterwards, be followed by a re-
 lapse.
   It  may effect a permanent cure."
   Mr. Fergusson has advised (Practical Surgery}, that after the division,
 the catheter should   be retained  for several days;  and in the paper by
 Prof. Syme, which was read at the Medical and Chirurgical  Society of
 London, April 26th, 1853, it is admitted that  there are "a few  excep-
 tional cases" in which it should be retained for 72  instead of  48 hours.
   The reader may find in Mr. Thompson's work the most impartial ex-
 amination  of this subject which has come under our observation.   It is
 fully  discussed in all  its bearings.
   The treatment  by progressive,  or rapid dilatation as recommended by
 Lallemand, MM. Chretien, Lasserre,Pirondi, and Benique has been rather
 favourably noticed by M. Velpeau in the text.  M. Lasserre employed 12
 different sizes of bougies, but M. Benique's  apparatus contains no less
 than  36, which  are  made of pewter, are cylindrical,  of the  ordinary
 curve, and flexible.  From 2 or 3 to 7 or 8 may be introduced at each
 sitting,  and if no irritation  be developed, the proceeding may be daily
 repeated.  If necessary to pass the largest size, the orifice of the urethra
 may be enlarged with a knife.  This method of treatment has been strong-
 ly advocated by Professor Eve, of Nashville, (Nashville Journ. of Med.
 # Surg. June, 1853, p.  332.)  His interesting paper concludes with the
 following propositions :
   1.  "That while dilatation is the the proper treatment for stricture of
 the urethra, this has  hitherto failed to effect a cure, because in the ordi-
 nary mode  of applying it, the seat of the disease has not been specially
 acted upon by the dilating instrument.
   2.  "To cure stricture, the orifice of tho urethra must be so enlarged
 that the canal beyond it may be dilated to its original size, which we ought
 to recollect is about  twice that of the opening leading to it.   Instead,
 therefore, of being satisfied with  introducing bougies of two lines in di-
 ameter through a restricted portion, they should measure four to Jive lines
 in thickness.
  3. " There is no necessity to confine a patient to bed in treating stric-
ture;  once an instrument has been introduced, it has done all itTcan to
expand the  passage and should be withdrawn,  that others larger in size
may be  immediately  substituted.   While this process ought to be cau-
tiously and very gradually conducted, still the more rapidly and freely it 
AMERICAN  APPENDIX.
941
 can be applied, provided no pain is excited, the sooner the disease will be
 removed.
   4. "By this method  (M. Benique's) strictures may be permanently
 cured in a few days, without  suffering,  inconvenience or  exposure to
 serious consequences."
   M. Perreve, of Paris, has recommended an instrument for the purpose
 of effecting  dilatation, which is designed to prevent the abrasion of the
 mucous membrane of the urethra, which  is so liable to occur in the use
 of the ordinary bougie.   His apparatus is dilated after it has passed the
 stricture, thus effecting  eccentric  dilatation only.  It consists of two
 blades  united at  the extremity, and these are separated by means of a
 screw.   As this instrument can act  but in one  direction, and  is liable
 to injure the mucous  membrane of the urethra which is apt to  protrude
 between  the  blades, Mr. Barnard Holt, of the Westminster Hospital,
 London, has  modified it, by passing between the blades  a guiding rod
 and tubes, by which the intervening space is nearly filled.
   Mr. Thomas Wakley, of the  Royal Free Hospital, London, resorts to
 an ingenious  contrivance, the object of which is to obviate one of  the
 difficulties in the  treatment by mechanical dilatation.   We refer to the
 trouble of replacing a small instrument, when, after having been passed
 with  great difficulty, it has  been withdrawn.   Mr. Wakley employs a
 wire  of very small diameter, which he calls the " urethral guide."  This
 is not withdrawn until  a straight  silver tube has  been passed over it
 through  the  stricture.  In this  manner  tubes of different sizes may be
 introduced, at the option  and discretion of the surgeon.
   The instruments to which we have referred  are all  intended, in the
 language of John  Hunter "to act like a wedge upon inanimate  matter."
 Mr. Guthrie  states, in his work on  the  Urinary  Organs (Am. ed. 1845,
 pp. 76, 77,) that more than thirty years ago, he had an instrument made
 by Mr. Weiss, for a similar purpose.   At first, it consisted of three blades,
 which were  gradually  separated by the action of a screw which turned
 in the handle.   Afterwards it was changed into a two-bladed instrument.
 " I thought I had now  obtained an instrument  which  could  not fail of
 fulfilling all my expectations, and was only disappointed in finding that
 it did too much.   The opportunity of dilating was in general too tempt-
 ing to be  resisted, and the consequence was, that it produced irritation
 in so  many cases, that  I was forced to give it up, having also  fully satis-
 fied myself that dilatation, to whatever extent it might be  carried, could
not cure the worst kinds of  stricture."
  Mr. Guthrie adds, that he does not now use instruments of this kind
but gives the  preference  to a pliable, hollow, gum elastic bougie  of a
median  size, perfectly  smooth, and  tolerably round at at the point so as
to give as little uneasiness as possible.  (Op. cit. p. 96.)
TENOTOMY.
  No one can deny that the opinions of surgeons have been considerablv
modified on this subject since the appearance of the last edition of th s
work.   At that time, tenotomy and myotomy were resorted to almost in 
942
NEW ELEMENTS OF  OPERATIVE SURGERY.
discriminately in every form of distortion that presented itself, but we
venture to assort that those who have had much experience in orthopedic
surgery are now much more cautious in recommending the division of
tendons than was formerly the case.  In a communication to the Amer-
ican Journal of Medical Sciences, for April, 1847, we thus expressed
our sentiments upon this subject:—
  We  are by  no means disposed  to underrate the importance of this
branch of surgery, but we do believe that its advocates have exaggerated
the benefits which it is capable of conferring.  They have too often led
the afflicted to believe  that in tenotomy and myotomy was to be found the
great panacea for every form of distortion, and that with the shape they
might expect the restoration of the functions of the affected part.  This
we  conceive in the majority of cases to be impossible.   When any part of
the body has been for years retained in an unnatural position, the struc-
tures of that part become so greatly modified as to render it impracticable
to restore them to their normal state.  Patients would derive much great-
er benefits from orthopedic surgery, were operative proceedings not so
much regarded as the sine qua non, but only as an important adjunct to
other powerful means.   Let the division of muscles and tendons in  cases
of contraction, and the  excision of a  portion of the tendon, where pa-
ralysis  exists, be faithfully followed by bathing, frictions, manipulations,
and  proper apparatus, and this department of surgery cannot be too
highly appreciated.
  The  Edinburgh Monthly Journal of the same year did us the honor
of quoting the above remarks, with approbation, and our subsequent ex-
perience and observation have fully convinced us of their accuracy.
                          TENORAPHY.

  This operation, condemned by Galen, but practised in the seventeenth
century by Veslingius, Severinus, Felix  Wurtzius, and afterwards by
Mainard, Bienaise, Purman and others, is likely  to  be  revived  at the
present day, and may doubtless in certain cases of divided tendons prove
of great  service.   We have recently had an opportunity of witnessing
a case of the kind, in  which, at  our  suggestion, this proceeding was
resorted to by Dr. Jas. L. Van Ingen, of Schenectady, N. Y.   The ten-
don of the triceps extensor cubiti had been completely severed by an axe,
and  it was impossible by position to retain the divided ends in contact.
Several sutures  were therefore employed ; and the wound progressed
very favorably, and in  a short time was completely healed.   The patient
has now, some six  months  after the operation, an excellent use of his
arm.   This  we are satisfied  would  not  have been  the  result had we
trusted to mere position  of the limb.  Those interested in this subject
may find a valuable paper on "des-Plaies et de la Suture des tendons,"
by J. T. Mondiere, iu  the Archives Generates de  Medecine, May 1837.
He has there detailed numerous cases establishing the propriety and
the advantages of this proceeding, and further confirmatory proof may be
found in the Journ. Conn. Aled. Chir., March, 1839, where are reported
two  cases successfully treated by M. Valentine.  The perusal of the 
AMERICAN APPENDIX.
943
papers above  referred to will  satisfy any one that Rognetta was wrong
in proscribing the suture of tendons as a useless and dangerous operation.
(Arch.  Gen. de Med. 1834.)
                   THYROID BODY, CYSTS OF.

   Mr.  Holmes Coote has  reported in the London Medical  Times  ana
 Gazette, for  November, 1854, the case of a large sanguineous cyst  oi
 the thyroid body, which he successfully treated by puncture and injection
 of tincture of iodine.  The cyst, which extended under the sternomastoid
 muscle to the anterior border of the trapezius, was developed in a healthy
 young married woman shortly after her first confinement.  It was thrice
 punctured.  There first flowed out sixteen ounces of colourless  blood,
 which separated into a firmish yellow  clot and serum.   Subsequently,
 the fluid  was of a pale-red hue, and much less in quantity.   An ounce
 and a half of the following was  injected through  a  trocar:—Tinct.
 iodine co., §j.; aquas, gv.   After the second injection the cyst disappeared
 entirely,  without inflammatory  symptoms.  In his Quarterly Report on
 Surgery  in the  British and Foreign  Medico-Chirurgical  Review for
 January, 1855, Mr. Coote in commenting upon the above case remarks :
 " M. Nelaton has used a similar injection with success, for the cure  of a
 biliary fistula, consequent upon the opening of an hydatid cyst by caustic
 potash.   He also injected a spina bifida without any bad results.  Bou-
 chut has  cured a chronic abscess (abscesfroid) by the same means, in a
 young_ scrofulous patient, in the Hopita'l Sainte Eugenie.  Dr. Giamb.
 Corelli has used the  injection equally successfully  in three cases of
 ranula, a disease which, according to  modern  investigation, seems by
 no means invariably connected  with dilatation of Wharton's duct.   Its
 seat is probably,  in many cases, a bursa, first described by Fleischmann,
 and situated upon the outer surface of the genio-hyoglossus muscle under
 the tongue.
 _ But it must not be inferred that iodine injections are  wholly without
 risk.  M. Nelaton  relates  the case of a young man suffering from Pott's
 disease—i. e., psoas abscess.   The injection of  tincture of iodine, one
 part; water, two parts, with as much iodide of potassium as was neces-
 sary to keep the  iodine in  solution, was followed, five hours afterwards
 by dizziness, disturbance of vision, sickness, coldness of the extremities'
 small pulse.   On the following  day, there was continued sickness, violet
 suffusion  over the eyelids, and  deep pain in the neck.   Active measures
 were resorted to, in order to get the poison out of the system—namelv
 emetics and purgatives  of croton oil.  Sinapisms were applied to the
 feet.  From these symptoms of poisoning the patient  recovered, but the
 disease remained in the same state as before.
   But inflammation, excited by any cause in a cyst, is commonly followed
 by serious consequences.  It may  ensue  from a simple puncture   \
young woman  was admitted into St. Bartholomew's Hospital April 21
 1803, under Mr  Lawrence, with a large cyst of the thyroid body; bound
down by the sterno-mastoid  muscle.   A  small trocar, introduced  into
the mesial line of the swelling, gave escape to six ounces  of sparkling 
944
NEW ELEMENTS OF OPERATIVE SURGERY.
brownish-red  fluid, composed of discoloured blood  and  cholesterine.
After a week, the fluid having re-accumulated, Mr. Lawrence re-opened
the original wound, and introducing a  director, cut open the  front of
the cyst with a bistoury.  The same quantity  of fluid  escaped, darker
coloured than  the preceding, accompanied by some bubbles of fetid gas.
Considerable constitutional  disturbance followed this operation ; there
was redness of the neck, violent pulsation  of the carotids, &e.  A cure
was effected by repeated injections of small quantities of the  compound
tincture of iodine."
  We have at  present a patient under our care, who for years has had a
Berous cyst of  the thyroid body, of  the size of a large orange.  Some
four weeks since we  introduced a seton, which was allowed to remain
for three days.   It produced a high degree of excitement, and a profuse
suppuration, but  these are rapidly subsiding, and we confidently hope in
a short time to find that the cavity of the cyst has become obliterated.
                  TONGUE, HYPERTROPHY OF.

   Mr G. M. Humphrey has reported in the 36th volume of the Medico-
 Chirurgical Transactions, London, an interesting case of hypertrophy
of the tongue, which he successfully treated by an  operation.  Mr. H.
has  analyzed the cases which he has found recorded, and has furnished
us with the following conclusions :
   "From the cases above  mentioned, and those described by other writ-
ers,  all  of which present great similarity in their general features, we
learn that the disease  is  one of sufficiently definite character to merit
special  notice.  Though it sometimes originates in an inflammatory af-
fection, it often  appears to be independent of any such cause.  It com-
mences  usually in childhood or early infancy, or is congenital.  If  it be
early attended to, it admits of an easy cure by compression.  If it  be
allowed to take its course, the prolapsing organ increases ; at first, in
greater proportion than the growth of the child.  After a time it would
appear to become stationary, or to grow only with the body, for in none
of the cases, even those in which the deformity had existed for many
years, had the tongue attained to greater size than one's fist.....Spon-
taneous cure rarely, if ever, takes place after the prolapse has been es-
tablished.  The  operation of removal is not attended with much danger,
and the remaining portion of the tongue shows no disposition to enlarge
again."  (p. 126.)
  Mr. Humphrey has  collected altogether  25  cases ; 6 of which were
treated by pressure, 7 by ligature, and 12 by amputation.   In one case of
ligature, and  one of amputation, the results were fatal; in all, the dis-
ease  was cured.
  To these cases, Mr. Hodgson supplies another, successfully treated by
ligature ; and  Mr. Teale another,  successfully treated by pressure. 
AMERICAN  APPENDIX.
945
                        TONSILLOTOME.

  The Journal des Connaissances Medico-Chirurgicales, for March 5th,
1854, contains the description and illustrations of two  instruments for
the purpose of excising the tonsils with which it is claimed the gland
may be removed with one hand.  MM. Maisonneuve and Blatin dispute
the priority in this modification, and the perusal of this controversy, with
the examination of the instruments, cannot fail to  amuse  surgeons in this
country who have been accustomed to employ the beautiful and ingenious
tonsillotome manufactured by Mr. Tieman, of 63 Chatham street, N. Y.
For some years past, he has made an instrument intended to be used with
but one hand, and his last improvement, as represented  in the annexed
figure, leaves nothing to be desired.
Vol.  IH.
119 
946            NEW ELEMENTS OF OPERATIVE SURGERY.

  The instrument of Fahnestock acted rather like a wedge, and if we
mistake not, until a comparatively recent date, most  of those employed
acted upon the same  principle.  The instrument, as now perfected, has
a double edge and cuts like a  pair of scissors, indeed, it may be called
a pair of  concealed scissors.   Instead of being straight, the handle is
now placed at a right angle, the advantages of which are obvious.  On
the upper  surface  of the instrument is a double perforator, resembling a
sharp-pointed  forceps.  When the  handle is  withdrawn, the  ends
of the forceps are brought together by  means of a spring, and the ex-
cised portion of the gland at  once  secured.  The action is such, also,
that the part removed is slightly elevated.   A gentle curve in the instru-
ment better adapts it to  the form of the  mouth.  It admits  of being
readily separated  so as to be cleaned.
  We have taken  some pains to examine the instruments for this opera-
tion made  by many of the most celebrated cutlers of Europe, and in our
humble opinion, their collection contains nothing, which, for elegance and
convenience, can  be compared with that  now  manufactured by  Mr.
Tieman.
  M. Chaissaignac, in a communication to the  editor of the journal
above quoted,  (March 15th, 1854) describes his method of performing
the simultaneous  ablation  of both  tonsils.   He has likewise furnished
numerous  illustrations of the speculum oris and the modification of the
tonsillotome which he employs.  His  speculum is intended at the  same
time to dilate the  mouth and to depress the tongue.
  Serious  and even fatal hemorrhage has sometimes followed the excis-
ion of the tonsils.  Beclard, Boyer,  MM.  Chaissaignac, Philip Boyer,
Monod and others, have witnessed  cases  of the kind.  Instances in
which the hemorrhage  was alarming, but  not fatal, have been  reported
by MM. Hutin, Moissenet, Gensoul, and  Vidal.  Professor Hamilton
of Buffalo excised one of  the tonsils in a patient, and such was the he-
morrhage  that he  did not venture to remove the other.  (Buff. Med. Jour.
Vol. V., p. 217.)
               TYMPANUM, PERFORATION OF.

  Among the indications for making an artificial perforation of the mem-
brana tympani, the reader will find mentioned in the text, closure of the
Eustachian tube, and a thickened  condition of the membrane.  In this
view of the subject the majority of writers coincide, but Mr. Wilde, of
Dublin, one of the highest and most recent authorities in Aural Surgery,
in his valuable work on " The Nature and Treatment of Diseases of the
Ear" Phil. ed. 1853, p.  283, declares that in closure of the Eustachian
tube,  the operation is neither required nor  applicable.  In cases of per-
manent thickening and opacity of the membrana tympani, which have re-
sisted all efforts at absorption and thinning, he believes it will seldom be
of benefit, because the opacity which is visible, forms but a portion of the
general thickening and disorganization of the investing membrane of the
middle  ear, and  perhaps of the  labyrinth, which we do not  see.  He
differs, also, with M. Velpeau, as to the serious character of the opera- 
AMERICAN APPENDIX.
947
tion.   He remarks that it requires great caution and dexterity in its per-
formance, and that irreparable mischief has at times proceeded from its
being  done in a rough or clumsy manner,   He  wholly discards all in-
struments in the shape of punches, trochars, and other complicated ap-
paratus for the removal of a portion of the membrane, because they so
fill the speculum as to conceal the point upon" which they are  pressing,
and  the extent of the portion removed.   With them, he  asserts, it is
scarcely possible  to avoid wounding the malleus, or inner 'wall of the
tympanum.  Further, those with  corkscrew points, which fix  the mem-
brane while the revolving punch cuts out  the  piece, " are  not only ex-
ceedingly painful, but dangerous, inasmuch as the slightest action of the
head  during the operation, might produce a degree of violence which
would  be destructive to this delicate structure."
  His  method of operating is as follows: Having brought the membrane
fairly within view, under bright, direct sunlight, he introduces the small,
fcickle-shaped knife, represented in the figure.
   The blade, which has a double cutting edge, is delineated of natural
 size, but the shaft and handle are about two inches longer than shown in
 figure.
   The patient is made to inflate the tympanum, so as to render the mem-
 brane tense, and pressed outwards, when the point of the knife is gently
 introduced  into its  inferior, thin, vibrating portion, and by drawing it
 downwards  and forwards, a simple incision is made  through the mem-
 brane, of about a line and  a half in length.  " So simple is this, and so
 little pain does it give, that the patient is often unconscious of its perfor-
 mance until made aware of its completion by the air rushing out through
 the  aperture.  In about a minute a slight  oozing of blood takes  place
 from the edges of the aperture,  like  that which follows a wound of  the
 sclerotic with an ordinary  broad cataract  needle;  if left in this condi-
 tion it will soon heal up ; therefore, a very fine probe, fixed in a handle,
 and slightly pointed with nitrate  of silver by being immersed in the caus-
 tic when heated to fluidity, should be  immediately passed down into  the
 perforation, the edges of which are thereby cauterized and prevented ad-
 hering ; and this latter process should be repeated from time to time, as
 often as the  wound  shows an inclination to heal,  and  until  we establish
 a sufficiently large elliptical opening."
   Mr. Wilde refers to a  paper read by Dr. Butcher, of Dublin, in 1846
 before the Surgical Society, the object of which was to show the ill con-
 sequences which sometimes result from perforation of the membrana tym-
 pani.  Dr.  B. related  the cases  of two young persons, a man  and a
 woman, in both of whom it would appear that death ensued from punc-
 turing the membrane.   Though these cases were defective in many im-
portant details, yet they strikingly illustrate the mischief which may  be
done, by a rude  and bungling operation.   These cases were reported in
the Dublin Medical  Press for April, 1846.
• 
943
NEW ELEMENTS  OF OPERATIVE SURGERY.
                          TRANSFUSION.

   We find in the Gazette  Medicate de Paris, for October 8th, 1853, a
 description of an instrument devised by M. Matthieu for simplifying this
            operation.  He has given  two wood-cuts illustrating differ-
  ^       ent instruments  which may be employed.   We copy  that
            which is the least complicated.  Fig. 1, represents a hollow
            sphero  made of vulcanised caoutchouc.   It  is  emptied by
            pressure with the hand, and expands again in virtue of its
            elasticity.  In this manner suction is made through both the
            glass tubes which  are attached to its extremities.
              One  of these tubes  terminates in a cup-like extremity,
            which is intended  to adapt itself accurately to the wound in
            the vein of the person supplying the blood; the  other, in an
            ivory canula, which is to be introduced into the  vein of the
            person receiving the blood.  In the latter tube, are two small
            cork balls, forming valves, which prevent the  reflux of blood
            into the vein of the  person from whom  it is drawn, which
            otherwise  might occur  at the moment when  the sphere be-
            comes flattened by the hand of the operator, or when it ex-
            pands again after  the pressure is removed.  Both tubes are
            attached to the sphere by means of caoutchouc, so that they
            can  be inclined in any direction without  derangiug the ap-
            paratus, or changing the position  of the  persons to  whom
            they are affixed.
              An anonymous  writer in  the Buffalo Medical  Journal for
            May, 1854, p. 733, after laboring to show that the transfusion
            of blood might safely be a much more frequent operation than
            it now is, remarks, that, a glass syringe inverted before inject-
            ing, so as to exclude all air from its chamber, and inserted
            into a single opening into the cephalic vein, guarded by the fin-
            gers of an assistant, is all the instrument required. The use of
           long tubes in his  opinion increases the danger of admitting
           air.  The transfusion of blood, he  asserts, has ever been a
           safe operation, even in the hands of those unaware  of its
           greatest  danger,  viz. the introduction of air into  a vein.
           He wonders that this remedy has so fallen into disuse, for it
           is one of those direct and  straight forward  cures, which
gladden the heart of a true physician, and give  him faith in the resources
of his art."
                       UTERINE SOUND.

  Prof. Simpson, of Edinburgh, has introduced into practice an instru-
ment intended  to  assist in the exploration of uterine affections, and to
remedy displacements  to which  this organ  is  so  liable.  It is called,
Simpson's  Uterine  Sound, and has the configuration of a slender male
catheter.  It has a  rounded and knobbed extremity, which is tapered 
AMERICAN APPENDIX.
949
 and curved.   The depth of the uterine cavity—2J inches—is marked on
 its convex side, and it has a handle, smooth on the posterior and rough-
 ened on its anterior surface.  When the uterus is  morbidly enlarged, as
 in  the  case of fibrous or other tumors, the elongation of its cavity can
 be easily measured with the bougie.   There are two elevations upon it,
 at  four  and a  half inches from  the  point, by which the physician  is
 enabled to take his measurements without withdrawing his instrument.
 The  dimunition in the  length of the uterine cavity may likewise be de-
 tected, by the elevations and depressions at different points of the stem,
 the whole length being nine inches. It is  made of silver, and its curve
 may be altered to suit the exigencies of the case.  This  instrument was
 brought forward in 1843, and has been extensively used both in Europe
 and in this  country.   There can be no question that in  many, perhaps,
 the majority of cases, it has produced no unpleasant effects, and has prov-
 ed of important service, yet fatal cases have been reported, as for exam-
 ple, in the Gazette des Hopitaux, Feb. 4th, 1854, where, after detailing
 a fatal case in his own  practice, M. Broca  refers to others in the  hands
 of MM. Nelaton, Cruveilhier  and Aran.   Further particulars as to the
 form and use of the instrument may be found in the Dub.  Quart. Journal,
 May, 1848, or in Dr. Peeble's Prize  Essay in the Amer. Journ. Aled.
 Sciences, July, 1853.   Dr. Bond, of Philadelphia, regards Prof.  Simp-
 son's instrument, as " a dangerous  weapon in the hands of  those bold
 chivalric practitioners,  who are determined never to be thwarted,"  and
 recommends  one of his own  invention, consisting of two  blades, the
 anal and the vaginal, with a clamp-headed screw and nut to fasten them
 together.  The anal blade has the larger curvature, (a radius  of about
 four and a half inches) and a square body three inches long, upon which
 the  other blade slides and rests, to which belongs  the handle  of the
 instrument.  The  vaginal blade  has a smaller curvature (a radius of
 about 3£ inches) so as to make the blades parallel;  it has a large groove,
 about two inches long, exactly fitted to  the square part of the other blade,
 so as to slide  upon it, and to obtain a  firm attachment by means  of the
 screw.   The end  of each  blade is terminated by an ivory tip, as large
 as can be conveniently introduced.  These are screwed on to the blades
 so as to  be readily  changed for  whatever size may be  required.   For
 further details we must refer to the American Journal of  Medical Scien-
 ces, April, 1849, p.  408, in which an illustration is given.  It certainly,
 from appearances, must be a safer instrument than that devised by Prof.
 Simpson.
   In a recent discussion of this subject before the Academy of Medicine,
 M. Velpeau stated that some fifteen or twenty years since he had resort-
 ed to this method for the purpose of rectifying the position of  the uterus,
 but  that it is a hazardous  proceeding,  and gives but temporary  relief.
 In five of his first cases, metro-peritonitis supervened  in two, and in con-
 sequence  of the risks  attached to this practice he thought it should be
 discountenanced.
  M. Moreau was of the same opinion, for, together with M. Amussat, he
had resorted to a similar method, but it was followed by such unpleasant
results, it was decided that its disadvantages more than counterbalanced
its advantages. 
950
NEW ELEMENTS OF OPERATIVE SURGERY.
                     VAGINA, IMPERFORATE.

   Dr. J. Mason Warren has  published  an  interesting paper on occlu-
 sion of the vagina, accompanied by retention of the catamenia, and has
 detailed three cases which were relieved by an operation. (Amer. Journ.
 Aled.  Sciences,  July,  1851.)  Cases  of a  similar nature have  been
 treated by Boyer, Boivin, Amussat,  Profs.  Mussey, Trowbridge, Ship-
 man, &c.  Some years since, we operated in a case, in which menstrua-
 tion occurred regularly from the mouth.  After dissecting some three or
 four inches between  the bladder  and the rectum, we  reached a cul de
 sac, the uterus being, as we have reason to believe, absent.   Prof. Mus-
 sey succeeded in  two cases, in which  the  adhesion was of four years
 standing.  One of the greatest obstacles to contend with after the ope-
 ration, is the great  disposition to contraction.  The  sponge tent may
 efficiently counteract this tendency, but, as in one of the cases reported
 by Dr. Warren, the extreme sensitiveness of the  parts may render it
 intolerable.  A  glass female syringe  was tolerated during the whole
 day,  the discharge passing off through the  calibre.  In Dr. Warren's
 first case, the patient barely escaped  with her life, and  as violent pains
 in the  abdomen, meteorism, and other symptoms of peritoneal inflamma-
 tion supervened, the canula employed  for dilatation had to be  removed.
 The operation for re-establishing an obliterated vagina by a simple punc-
 ture proved fatal  in the hands  of Mr. Liston, .and a similar result occur-
 red in this city.
   We  copy from  the New- York Medical Times, for October, 1852, the
 following observations upon this subject by T>f. Mott.

 Case of complete Occlusion of the Vagina, with remarks.  By Valen-
   tine Mott, M. D., Emeritus Professor of Surgery in the  University
   Medical  College, &c.

   We have encountered a number of  instances of the entire closure of
 this passage.  Some  have  been congenital, and others  the result of in-
 juries, followed  by violent inflammation.  In infants and children wo
 sometimes  see a congenital  union  of  the labia majora or labia minora,
 which is confined  to those structures only, and is very trifling.  In those
 cases, where  the thin pellicle of membrane is divided, the entrance into
 the vagina  can at once be seen, provided the  hymen is perforated.
   We have seen instances of a complete want of vagina, in which there
 was no room  for this passage,  and, owing to  the relation of parts, none
 could be made by art.
   In three  cases which have presented themselves to us in young women,
 recently married,  two had to submit to be divorced, but the third was not
even asked to be separated  from her husband.
  In the two first  cases there was no room whatever between the urethra
 and rectum for the formation of a vagina, as  a catheter or sound passed
into the bladder could be felt through  the whole of its track to the  blad-
der, as plainly and distinctly as an instrument could be felt in the mem-
branous part of the urethra of  the male, with the finger intra anum.
  The two females were both young, and with every other external de- 
AMERICAN APPENDIX.
951
 velopment  as perfect as nature could bestow.   The only abnormal con-
 figuration,  which, without close inspection would not have been noticed,
 was the close proximity of the urethral opening to the anus, leaving as it
 were  no perineum.   Of course, neither  of them had ever menstruated.
 As  a vicarious office, the bowels were affected with diarrhoea about every
 twenty-eight days which lasted two and three days.
   As there never had been any menstrual accumulation, and as no uterus
 or cervix could be felt from the rectum, my belief is, that they both were
 without a uterus, but that the ovaria were present in both of  them.
 From imformation  which I received, I am  warranted in the  latter con-
 clusion.
   In the third  case, the closure was on a line directly backwards from
 the meatus urinarius.  She had been married  a number of years, and
 from frequent pressure against the barrier, it was broad, and warranted
 an attempt being made to find the os uteri.   Accordingly, with my finger
 in the  rectum, and  the external  parts separated, I plunged a pointed
 bistoury  to the  depth of about three inches, and cut laterally and per-
 pendicularly, so that my finger was readily admitted its full length.
   A conical  piece of dry  sponge was now introduced to the full extent
 of the cut, and  kept in for several days ;  when removed, another was
 passed up, and  by a careful repetition  of them from time  to time for
 several weeks, I thought  the full extent of the incision would be pre-
 served, but by degrees  it began again to  contract, and in defiance of all
 my  efforts and expectations, the opening completely closed, and the parts
 returned to their former condition.
   From  circumstances which she made me acquainted with, I am  confi-
 dent she  had a uterus, but was without ovaria.   She never had any men-
 strual accumulation, but the periodical diarrhoea, which, as she said, re-
 lieved her system.
   In the  three  traumatic  closures which I have seen, there was in the
 first two a  small opening  which led to the vagina ;  in one, directly be-
 low the meatus urinarius, the opening was only sufficient to admit a  small
 probe.  They were  both  occasioned  by instruments used in delivery.
 Both were  cured by incisions, and one by the continued use of conical
 pieces  of sponge.  Menstruation had not  been interrupted in either
 of them.
   The third case was in an interesting young woman, about twenty-five
 years  old, who  came to me from one of the Sandwich  Islands for the
 express purpose of seeing  if some operation could not be performed for
 her relief.  She  had been  married for several years, and had been en-
 ceinte once.   Between the third and fourth month of her pregnancy she
 aborted.  Before and after the ovum was  discharged, she had a profuse
 hemorrhage which induced the practitioner to resort to the tampon.   For
 some days  after the  tampon was discontinued, she suffered excessively
 from pain and  inflammation of the vagina, and when she recovered,
 found  that the female passage had entirely closed.   To such a degree
 was  it closed as to prevent all intercourse.
   When she arrived  in this city, and came  under my care, I found her
 in  rather  delicate health, not having menstruated for between two and
three years, the period which had elapsed since  the  abortion.   For
several  regular  periods after recovering from the puerperal  state, she 
952            new elements  of operative surgery.

felt some  of the usual  sensations incident to the  menstrual period, but
they gradually left her.
  With high intellectual endowments, she  suffered at times  from con-
siderable moral depression ;  but her resolution was unflinching to submit
to an operation if it held out any hope whatever of relief.
  On making an examination, I found the vagina completely closed from
the  lower  margin of the meatus, across to near the point of the begin-
ning of the perinasum.   The barrier thereforo had an oblique direction
from before  backwards, extending farther behind than in front;  all the
other external parts were in a normal state.
  I explored carefully  the obstruction in all directions, but  could not
detect at any part the smallest opening leading into the vagina.   I repeat-
ed this examination several times.
  With a  finger in the  rectum, I could distinctly feel the  neck of the
uterus  ; and when a sound  was passed through  the urethra, there ap-
peared to be some space (though small) for an opening to be made to
the  os  uteri.
  There  was not  any  fullness about the lower part of the abdomen to
the  sight or touch, to lead  to a belief that there was any catamenial
fluid collected in the uterus,  nor a sense of fullness to denote its deten-
tion anywhere.
  I now explained to her the nature of the operation her case required,
and stated to her that  it was difficult, though not dangerous  ; and that
if I did not succeed in  it, she probably would not be in a worse condi-
tion than  at present.  She  replied that she wished it to be performed,
if there was even a chance of success, though her life should be perilled
by the  operation.
  The  operation being decided upon, she was directed an enema a short
time before the  appointed time, in  order to evacuate the rectum and
bladder.   She now placed herself upon a table of convenient height, and
at her  request was placed under the influence of  chloroform.  She was
then drawn to the  end of the table and placed  in the position as for
Lithotomy, the knees being supported by  assistants.
  A male sound was now  passed into the bladder, which I confided to
my  son, Dr. Alex. B. Mott, with directions that he should draw the
urethra and neck of the bladder as close as possible under the arch of
the pubes, and with two fore fingers of the  other hand to separate the
external parts.
  Being now seated in a chair, lower than the ordinary height, with the
fore finger of the left hand into the rectum, so that I felt distinctly the
neck of the uterus, I passed a straight French bistoury to the depth of
three inches, entirely up to the  neck of  the uterus, as felt through the
rectum.  I then cut downwards to the  rectum to  the whole  extent of
my  finger, so as to leave in  my judgment only  the rectum.  The edge
of the  knife was next turned upward, and the cut made in that direction
as far as I dared to go.   Then a transverse  incision on each side.  The
fore finger was now readily admitted into the opening up to  the  cervix
uteri, but I could not distinctly feel the os tineas.
  After sponging out the wound and waiting a few minutes for the bleed-
ing to  cease, I passed up a delicate ivory speculum provided for the pur-
pose, about two and a half inches in length,  but could not  discover the 
AMERICAN  APPENDIX.
953
mouth of the womb.  I now passed in the knife again, and, made several
smaller incisions in different directions about the os uteri, when suddenly
but slowly, there  ran from the wound three to four table  spoonfuls of a
fluid of a very dark venous color, and of the consistence of thin molass-
es.   This satisfied me that I had made a communication with the mouth
of the uterus.  In these  latter  incisions, I felt that there was a great
danger  of opening the upper part of the urethra or the bladder, and
thereby leave a vesico-vaginal fistula;  I therefore  cut with  great  deli-
cacy and care.
  The wound was now syringed out with warm water, and  a conical piece
of fine, dry sponge was compressed between  the  blades of a  slightly
curved  polypus forceps, and passed up to the bottom of the wound.
  The dark fluid  which ran  out  resembled in color venous  blood as we
have often seen flow in operations from cutting  veins of considerable size
while the patient was under full  anesthesia.
  On recovering  from  the anesthesia, she took  a few drops of Majendie's
solution of morphine, more to allay irritation and nervousness, than for
any considerable  amount of pain.
  The day following the operation she was very comfortable.  The pres-
sure of the sponge upon the urethra made it necessary to use the cathe-
ter a few times.  But as soon as she felt a confidence that a little effort
would not injure  her, she  had no further difficulty.
  Low  diet and  quietness in bed  were  enjoined.  After three days the
sponge  was removed and another one introduced.  To accomplish this*
without pain, she was  put under the moderate influence of  chloroform.
Before  the sponge was removed, she took a mild aperient every two and
three days ; after this the  sponge was changed, and a smaller quantity
of chloroform,  by her  earnest entreaties, was  administered. After the
second  sponge she began to sit up, and soon became  very comfortable.
Several ounces of the dark fluid continued to be discharged for two weeks
or more after the operation.
  Then again, at her  regular  period, there   was quite a considerable
amount, and again at the  next period it occurred  again.  At this third
menstrual period it had a  fresh natural color.   From this time it was es-
tablished at regular periods and of a natural color.
  After using the bare sponge for a few times, I substituted the sponge
inclosed in a small oil silk bag,  the bag being  large enough  to allow the
sponge  to expand and open at the larger  extremity.  This was found
much less irritating than the naked sponge.
  She now began to change the  sponge herself every day,  and rapidly
regained her health and spirits,  and began to  think of returning home,
after having been under ray care about four months.
  Before she left, I advised her to continue the  sponge daily until she
arrived home.
  The  gratification  I felt in the result of this case  compensated for a
failure  in some others, and this was  greatly enhanced by  the  joy and
gladness it gave  my patient.
  vol.  in.                       120 
 
INDEX.
 Abdomen bandages,      .     i., 169, L 195
       Compression of arteries of,     i. 688
       Foreign bodies in,     .    .  ii. 739
       Operations on,  iii. 195, 903, 911, 864
       Paracentecis of,            . iii. 195
       Parietes of abdomen, tumors,
         in,.....iii. 213
       Subcutaneous bridles and cic-
         atrices of the abdomen,    .   i. 395
 Abdominal aorta, wounds of, i. 901, 672, 804
 Abdominal or Caesarean section,    iii. 911
 Abscesses, connected with Aneurism,  i. 667
 Abscess of the bladder,       .     . iii. 638
       after high operation of lithot-
         omy,     .... iii. 638
       of bone,     .    .     .     .  ii. 544
       cold,.....ii. 606
       of cranium,     .     .     .  ii. 773
       of female labia,  .     .     . iii. 450
       of liver,      .     .   ii. 532, iii. 207
       opening of abscesses,          i. 340
       of purulent  infection,  .     .   i.   77
       of rectum,   .... iii. 930
       a remarkable case of,  .     . iii. 938
       rupture of an abscess into in-
         ternal jugular vein,  .     .   i.   34
       of tonsil,    .... iii.   56
       of liver from wounds of the
         head,     .    .    ii. 532, iii. 207
Accidents during operations,  .     .   i.   18
       after operations, .     .     .   i.   65
       after amputations,      .     .   L 118
       after operation  for Strabismus, i. 522
Acids, mineral, as caustics,   .     .   i. 297
       their use in erectile tumors,   ii. 560
Acromial end of clavicle, exsection
         of,.....ii. 495
Acromion, hematic cysts  of, .    .  ii. 652
Actual cautery, i. 302—see Caustics.
Acupuncture,      ...     .   L 346
       in aneurisms,    .     .     .   i. 709
       in erectile tumors,    .    .  ii. 562
       in hernia,   .... iii. 257
       in hydrocele,    .     .     . iii. 397
       in un-united fractures,     . ii. 304
       in varices,   .     .    .     ii.  3,  13
Adhesive plasters,  as bandages,      L 207
       as strips,    .    .     .     .  i. 127
       in fracture of the leg, .    . iii. 898
       in ulcers of the  groin,      . ii. 592
jEther and chloroform, use  in opera-
         tions,     .    .     .    .iii. 822
Adhesions, morbid, of the  abdomen
         and genitals,  .     .     .  i. 395
                                     PAGl
Adhesions of the arm,   .     .     .   i. 392
      of the cheeks,    .     .     .  ii.  23
      of the eyelids,    .     .     .  ii. 830
      of the fingers,    .     .     .   i. 387
      of the fore-arm,  .     .     .   i. 391
      of the legs,       .     .     .   L 394
      of the neck and trunk,      .   i. 396
      of prepuce to glans penis,    . iii. 444
      of the tongue,    .     .     .iii.  42
Agaric or Punk, in dressings,      .   i. 110
Air, application of hot,      .        i. 219
      in veins,   .    .     .     .   i.  20
      entrance of air in veins, how
         prevented,    .     .     .   i. 229
      passages, operations  on,    . iii. 136
      expulsion of  foreign bodies
         from air passages,   .     . iii. 155
      pump cupping-glasses,.     .   L 275
Albuginea tunica of the testicle, its
         incision in cases of Orchitis, iii. 759
Alimentary   passages,   operations
         on,      .... iii. 151
Alneolar hemorrhage,  .     .     .   L 693
Alveoli, operations on,        iii. 421—428
      perforation of,        .     . iii.  93
Amaurosis with strabismus  .     .   i. 534
       section of mnscles of the eye
         to relieve amaurosis,     .   i. 547
Amblyopia, or confused vision after
         the operation of Strabismus,  i. 543
American aneurismal needle,      .   i. 917
American Appendix,     .   iii. 819—950
            under this head, see
      Ankylosis, cases of,   .     . iii, 819
         of knee-joint,  .     .     .iii 821
      Ancesthesia,     .     .     , iii. 821
      Anus, artificial  .     .     . iii. 836
         imperforate,   .     .     . iii. 837
      Bladder, puncture of, .     .iii 838
         extraction of foreign bodies
            from the bladder, .     . iii. 840
      Bronchiotomy,   .     .     . iii. 841
      Carcinoma, .    .     .     . iii. 847
      Chloroform,      .     .     . iii. 821
      Cataract,   .    .     .     .iii. 850
      Cold, as an anaesthetic,     . iii. 826
      Collodion, use of,      .     . iii. 852
      Dislocations, a  new  mode  of
         reducing,      .     .     .iii. 853
      Dislocations, congenital,     iii 853
      Emphysema of eyelids,      . iiL 856
      Enterotomy,     .     .     . ijj. §62
      Epiphora,   .    .     .     . iii. 866
      Epispadias,      .     .    . iii. 867
      Empyema,       .     .     . iiL 856 
956
INDEX.
American Appendix—continued.
      table of cases of empyema in
         which paracentesis was per-
         formed,   .... iii. 858
      Fistulos recto-vaginal,      . iiL 868
         vesico uterine, .     .     .iii. 872
         vesico utero vaginal,     .      ib.
         vesico vaginal,        iii. 874-888
      Fractures,   .... iii. 888
         of clavicle,     .     .     . iii. 889
         of femur, .... iii. 893
         of leg,    .... iii. 898
         of humerus,    .     .     . iii. 890
         of patella,      .     .     . iii. 896
         of radius, .... iii. 892
      un-united fractures, new method
         of treatment and perforation of
         bone.....iiL 900
      Gastrotomy, remarkable cases
         of,.....iii. 864
      Hare  lip, operations,   .     . in. 902
      Hernia,     .... iii. 90#3
      Hydrocele,  .... iii. 90*7
      Hyotocephalus,   .     .     . iii. 908
      Hysterotomy, or Caesarean sec-
         tion,     .... iii. 911
      Hysterotomy vaginal, .     . iii. 912
      Tridoplasty,      .     .     . iii. 913
      Larynx, morbid growths in, iiL 914
      Lithotomy,  .     .     .     . iiL 915
      Lithotrity.....iii. 917
      Liver, paracentesis of,      . iii. 918
      ^Esophagotomy,  .     .     . iii. 919
      Opthalmoscope,   .     .     .iiL 921
      Ovariotomy,      .     .     . iii. 922
      Penis, anaplasty  of,    .     . iii. 923
         rupture of,     .     .     .iiL 924
      Pericardium, paracentesis of, iii. 927
      Polypus aural,    .     .     . iii. 928
      Ranula,   .... iii. 929
      Rectoplasty,      .     .     . iii. 930
      Rectum, abscess  of,    .     .      ib.
      Septum nasi, hypertrophy of, iii. 934
      Speculum oris,    .     .     . iii. 935
      Spina bifida,      .     .     . iii. 935
      Strabismus, .... iii. 938
      Strictures of the urethra,    . iii. 939
      Tenotomy,   .... iii. 941
      Tenoraphy.....iii. 942
      Thyroid gland, cysts of,     . iii. 943
      Tongue, hypertrophy of,    . iii. 944
      Tonsillitome,     .     .     .iii. 945
      Tracheotomy in croup,      . iii. 846
         new mode of performing,  . iii. 84?
      Table of cases requiring trach-
                                  iii. 842
                                  iii. 948
                                  iii. 946
                                  iii. 984
                                  iii. 950
                                   ii.  58
                                   ii.  69
                                   iL  82
                                   ii.  84
                                   iL 118
                                    I 196
                                   ii.  82
         eotomy,
      Transfusion of blood,
      Tympanum, perforation of,
      Uterine, sound,   .
      Vaginal occlusion,
Amputation of the limbs,
      in cases of aneurism,
      ankylasis,   .
      ankylosed fingers, &c,
      accidents from amputation, .
      bandages used in amputation,
      for bites of rabid animals,  .
Amputation—continued.
      for deep burns,   .
      for caries,
      for cancer,
      for congelation,   .
      counter-indications to,
      continuity, amputation  in,  .
      contiguity.....
      for deformities,   .
      dressings   and   subsequent
  PAOB

ii.  68
ii.  78
ii.  78
ii.  67
ii. 867
ii.  99
ii. 108
ii.  83

ii. Ill
ii.  63
i. 105
ii.  69
    64
    73
    62
    60
    76
    56
ii. 276
u.
ii.
iL
ii.
ii.
iL
  treatment,
for injuries  and external vio-
  lence.....
flap operations,  .
for fractures and luxations,
for gangrene,  spontaneous,
for gunshot wounds,   .
for hospital gangrene,
indications tor amputation,
for injuries, rail-road,
for injuries of nerves,
limbs, artificial,  .
for limbs almost divided,
limbs, supernumerary,
limbs, how saved,
for necrosis,
operative methods,
organic changes from, .
particular amputations,
period when to amputate,
place where to amputate,
preparations for, .
prognosis of amputations,
for rail-road injuries,   .     .  ii.
saving of limbs from,  .     .  ii.
suppuration, after amputation, ii.
tables, statistical,  of  amputa-
  tions, showing the mortality
  from,
tables of results of,
tetanus from amputation,
toes crooked,
ulcers, lupus, Ac,
white swellings,  .
wounds   from  rail-road
  juries,    ....
wounds, gunshot,
in particular,
of the arm,
of the arm and scapula, avul
  sion of,
of the arm at shoulder joint,
clitoris,     ....
of the fingers,
of the fore-arm,
of the foot,
of the hand,
of the hip-joint,      .   ii. 255—271
statistics of the hip joint opera-
   tions,     .     .     .     .  ii. 257
of the knee-joint, L 950—iL 236, 243
of the leg,  .     .     .     .  ii. 222
iL 82—87
 . ii. 271
 . ii.  77
 .  L  99
 . ii. 130
 . ii. 136
 . iL  89
 . iL  95
 . ii.  96
 . ii. 131
 . ii.  76
 . ii. 271
       79
   iL 133
 .  ii. 184
 .  ii.  80
ii.  82—87
ii.  80—86
 .  ii.  79
in-
 .  iL  76
 .  ii.  73
 .  ii. 136
 .  ii. 170

   ii. 188
   ii. 173
   iiL 446
 136—147
 .  ii. 162
 .  ii. 215
 .  ii. 159
of the lower jaw,
limbs, how saved,
of the metacarpus,
of the metatarsus,
of the penis,
 ii. 329
 ii. 271
 ii. 147
 ii. 195
iiL 446 
INDEX.
957
Amputation —continued.
       saving of limbs by conserva-
         tive surgery,  .    .     .  iL 271
       scapula and arm, avulsion of, iL 188
       at the shoulder-joint,  .  ii.  173—185
       statistics of operations on the
         shoulder-joint,  arm   and
         thigh,    .     .    .    .  iL 185
       of the tarsus,    .    .     .  ii. 207
       of the thigh,    .    .    .  ii. 246
       of the toes,  .    .    .     .  iL 193
       of the wrist,     .    .     .  ii. 159
Anal bandages,    .     .    .    .  i. 176
Anaplasty, or Autoplasty,   .    .  i. 550
       in artificial anus,     .    .  L 619
       in blepharoplasty, or  trans-
         planting of the eyelids,  .  i. 636
       for cicatrices of burns,    i. 608, 641
       of the cranium,  .    .    .  i. 610
       of the cheeks and lips,     .  i. 628
       of the cornea,    .    .    .  L 635
       Cheiloplasty, cases of,    L 638, 655
       Chalinoplasty,  or restoration
         of the fraenum  of  the pre-
         puce,     .     .    .    .  i. 657
       Cutaneous bridge, transplant-
         ing,      .     .    .    .  i. 609
       Deformities, anaplasty in,  .  i. 658
       Eyelids, anaplasty of, .    .  L 636
       Episcoraphy, or Episcoplasty, L 644
       Fistulas stercoral, anaplasty in, i. 619
       vesico and recto vaginal,  .  L 661
                              iiL 874—887
       Fraenum of prepuce, restora-
         tion of,   .     .     .     .  i.  657
       Fingers and toes, anaplasty of, L  590
       Flaps remote, by anaplasty,   i.  603
       Forehead, anaplasty of,     .  L  633
       Harelip,    .     .    .    .  i  640
       Indian method of anaplasty,   i.  605
       Incisions or scorings,  .     .  L  608
       Invagination,    .     .     .  L  610
       Keratoplasty,  or  the  trans-
         planting of the Cornea,   .  i.  635
       Lips,  anaplasty of the, .     .  L  628
       Metroplasty,     .     .     .  L  644
       Nose, anaplasty of,   .   L 591,  638
       Otoplasty,   .     .    .     .  i.  611
       Organs partly divided,      .  i.  559
               completely,    .     .  i.  593
       Palatoplasty,     .    •    .  i.  657
       Plastic operations, after  burns, i.  658
       Penis, anaplasty of,    i. 645, iiL  923
       Posthioplasty,  or restoration
         of the prepuce,      .     .  i.  657
       Perinaeum,  anaplasty of,    .  i.  628
       Eemote flap, anaplasty of,  .  i.  603
       Rhinoplasty,     .    ■     .  i.  638
       Recto-plasty,    .     .     . iii.  930
       Recto-vaginal plasty, L 627, iii. 874—
                                       887
       Separation or sliding of tissues, L  606
       Stercoral fistulas,      .     .  i.  619
       of scrotum and penis,  .    .  i. 621
       Transplantation,      .   L 599, 609
       Urethra, anaplasty of, .    .  i. 622
       Vagina,          i. 624, 651, iii. 874
Anaplasty—continued.
       Vagino-rectal,        i. 627, iiL 874
       Vesico-vaginal,  i. 661, iii. 874—887
       see also Appendix,   .     .   lv.
Anastomosis, aneurism by,   .     •  i» 912
       case of ligature of the carotid,
         for,      .    .    .     .  L 950
       medical treatment of,  .     .  L 674
       table of operations, upon,   .  i. 669
           see Aneurisms,   .     .  L 665
Anchyloglossus, or adhesion of the
         tongue.....iii.  42
           see Tongue,
Anchylosis,        .    .    i- 484, iii. 819
       amputation in cases of,     . ii.  82
       excision,   .    .    .     •  L 485
       fracturing of,                 i- 485
       making new articulations  in
         cases of,       .    .     .  i. 489
       perforation of bone, in  cases
         of,.....iii. 821
       of the elbow,    .    .     .  i-489
       of the foot,       .    i 486, iii. 821
       of the hand and fingers, L 489, iiL 819
       of the hip joint,  .    .     . iii. 819
       of the knee,      .    L 486, iii. 821
       of lower jaw,  i. 748, iii. 21,  811, 819
       see Immobility of the Lower
         Jaw.
Ancient hernias—see Hernia,      . iii. 333
Anel's method of ligating arteries for
          the cure of Aneurisms,    .   i. 728
Anaesthesia, in surgical  operations,  iii. 821
       local,.....iii. 825
       see Chloroform and Ether.
Aneurisms,.....i. 665
       abscess with,     .   .     .   L 667
       acupuncture in,  .    .    '.   i. 709
       accidents in operation for, i. 744, 747
       Anel's method in treatment of,  i. 728
       amputation in cases of,     . iL  69
       by anastomosis, L 912, 950, 674, 669
       aneurismal varix,    L 698, 823, 779
       varicose,   i. 779, 818, 799, 823, 961
       axillary,    .     .    .   i. 898, 951
       causes of death from, .     .   i. 844
       capillary and circoid, .     . ii. 573
       cauterization in,  .   .     .   i. 701
       changes in vessels,  after lig-
          ature,    .     .   .     .   i. 748
       cirsoid,     .     .   .     . ii. 573
       compression in,  .    .  i. 679, 694
       crushing in,      ...   i. 708
       diagnosis of,     ...   i. 878
       double ligatures  and artery,
          dividedtbetween,   .     .   L 723
       dressings after operation for,   L 742
       diathesis hemorrhagic in,      L 747
       diffused false, from  gunshot
          wounds,                 .   L 962
       erysipelas, after operation for,  i. 746
       fact  important concerning, see
          Appendix to vol. i. .     .   xliiL
       femoral, case of,  .   .     .   L 953
       frequency of,                  i. 669
       galvano puncture in,  .     .   i. 711
       gangrene after operation for,   i 747 
958
INDEX.
Aneurisms—continued.
       heat, treatment of, by .     .   i.  711
       hemorrhage after operation for, L  746
       ligatures in treatment of,    .   i.  712
       various kinds of ligatures and
         their effect,  .    .    i. 718,  719
       various methods of  ligature,
                          L 727, 733,  907
           see Arteries, ligature of,   i.  712
       obliteration of arteries by,      i.  719
       operation by ligature, how per-
         formed.....i.  738
       plebitis after the operation for,  i.  747
       refrigerants, &c. in treatment of, i.  676
       remarks on,      ...   i.  891
       eac  anourismal,  inflamed or
         gangrenous,   .    .     .   i.  667
       spontaneous cure of,  .     .   i.  668
       setons and pins in treatment of i.  721
       surgical treatment of, .     .   i.  678
       table, statistical of operations
         for,       .     .    .     .   i.  669
       treatment of,     .    .     .   i.  674
       varicose,         .    .   i. 779,  818
       varix, aneurismal,     i. 698, 823,  779
  Particular Aneurisms—
       of the abdominal aorta,    i. 805,  901
       of the auricular artery,      .   i.  844
       of the axillary,  i. 951, 826, 896,  962
       of the anterior tibial,      i. 760,  907
       of the basilar,    .    .     .   i.  853
       of the brachial,  .    .   i. 820,  899
       of the carotid primitive,  L 897, 911,
                                 859,  863
       of the carotids secondary,      i.  857
       of the common iliac,    . i. 802,  901
       Qf internal  arteries of cranium,  i.  845
       of the dorsalis  pedis,  .     .   i.  757
       of the elbow,     .    .     .   i.  815
       of the external iliac, L 785, 903,  941
       of arteries  of face,    .     .   i.  848
       of the femoral artery,  i. 772, 907,  953
       of the fibular,    .    .     .   i.  756
       of the gluteeal and ischiatic,   i. 794,
                            904, 799,  961
       of arteries of tho hand,    i. 809,  900
       of arteries of the head,    L 844,  848
       of the iliac, common,      i. 802,  901
       of the iliac, external,  i. 785, 903,  941
       of the iliac, internal, i. 792, 961,  904
       oftheinnominata, i. 876, 883, 894,  945
       of the internal mammary,   .   i.  889
       of the intercostal,     .     .   i.  889
       of the Ungual,    .    .     .   i.  849
       of the occipital,  .    .     .   i.  848
       of arteries of the ptenis,      .   i.  890
       of the pharyngeal,    .     .   i.  856
       of the popliteal,  .     .   i. 768,  901
       of arteries of the shoulder,  .   i.  889
       of the subclavian,    i. 833, 894,  909
                            914, 956,  966
       temporal,                   .   L  846
       thyroid,     .     .    .     .   i.  851
Aneurismal American needle,      .   L  917
Angioleucitis,      .    .    .     .   i.  74
Angina cedematous of the larynx,  . iii.  137
Animal ligatures,   .     .    .     .   i.  714
Animal magnetism, its influence  in
         preventing pain,    .     .  i.  23
Ankle, exsection of the malleoli,  .  ii. 429
Ankle-joint, exsection of,     .     .  ii. 486
       cysts connected with, .     .  ii. 656
       ligaments of, divided for rig-
         idity,    .    .     .     .   L 476
       tenotomy of,          .     .   L 451
       tarsal end of fibula,  exsccted, ii. 487,
                                      292
Anomalies of arteries—see Arteries.
Anterior chamber of the eye, pus in, iL 900
Anterior tibial artery, ligature of, i. 760 907
       wounds of,       .     .     .   L 759
Anterior libial nerve,   .     .     .   i.  52
Anticardiac,   Brasdorean,  or  distal
         method of  treating  aneu-
         risms,    .    .     .   i. 730, 897
Antrum Highmorianum, diseases of, iii.  93
       foreign bodies in,     .     .  iii.  97
       osseous cysts,  and tumors of, iii.  99
       polypi of,    .    .     .     . iii.  97
           see Maxillary sinus.
Anus, artificial,  anaplasty of,      .   i. 619
         bandages for,  .     .     .  i. 176
         cancers of the anus, .     .  iiL 805
         contraction  of, .     .     .  iii. 765
         division of sphincter ani,  .  iii. 545
         extirpation of anus,.     .  iii. 777
         fissure of anus,     .     .  iii. 780
         fistulas of,                 iii. 788
         foreign bodies in,    .     .  iiL 768
         imperforate  anus,     iii. 758, 837
         prolapsus  ani, .     .     .  iiL 775
         anaplasty  for, .     .     .   i. 619
Artificial anus,      i. 619, iii. 297, 762, 836
       after femoral hernia and the
         operation  to remedy it,     iii. 905
Aorta,  aneurisms of abdominal,  i. 805, 901
       dissecting aneurism of thoracic,
         Appendix L, lx.
       compression  of the,    .     .   i. 688
       ligature of,       ...   i. 804
       wounds of,       .     .     .   L 67 2
Aponeurosis of muscles of the eye,    i. 611
Apparatus auditory, operations  upon, iiL 100
       urinary,     .    .     .     .  iii. 560
Appendix to vol. i. of this  work—
       L  xliii.  to  lxiii., containing
       many facts relative  to ampu-
       tation, exsections,  of  lower
       jaw, clavicle,  &c, removal of
       the thyroid  gland, hydrocele,
       &a, &c.
Appendix American,   .     .     .iii. 819
Arabian  elephantiasis,  .     .     .   i. 782
Arch zygomatic, exsection of,     .  ii. 328
Arm, amputation of,    .     .     .  ii. 170
         at the shoulder-joint,     .  ii. 173
       anchylosis of,                 i. 489
       avulsion of, and scapula,  i. 888, iL 188
       bleeding from  the,     .     .   L 236
       exsection of,    .     .   ii. 288, 407
       fatty tumors of the,    .     .  ii. 627
       lymphatic tumors of the,    .  ii. 592
       neuromas of the,      .     .  ii. 614
       subcutaneous hidles of the,  .  L 392 
INDEX.
959
Arrest of blood ia a limb to  be re-
         moved,  .    .     .    .  L  20
Arteries,.....L 662
       acupunctature of,      .    .  i. 709
       cauterization of, .     .    .  i. 707
       compression of,  .     .  i. 679—688
       facts important relative to lig-
         ature of—see Appendix L  xliii.
       galvano-puncture to,  .     .  i. 711
       lesions of,   .     .     .     .  L 665
       ligature of, and its effects,   .  i. 711
       medical treatment of diseases
         of,.....L 674
       method  of tying arteries, the
         dressings after, &c, &c.   .  L 907
       surgical  treatment of diseased, i. 678
       wounds  of,       .     .     .  L 670
Arteries in particular, ligatures of, and
          operations upon them.
       anterior tibial,  .      .   i. 760, 907
       arteria   innominata,  diseases
          of,  and ligature of,   L 866, 874—
                              883, 894, 945
       brachial artery,     .    i. 820, 899
       carotids primitive,    i. 850, 863, 867
          869—874, 897, 909, 931, 945, 950
       carotids secondary,    .     .   i. 857
       common iliac,   L 802, 903, 941, 961
          see also Appendix  .     .  i. lv.
       of the interior of cranium,  .   i. 845
       dorsalis pedis,    .     .    .   i. 757
       epigastric,       i.  890, iii. 350, 356
       external iliac,        L 785, 905, 953
       external maxillary,    .    .   L 849
       of elbow.....L 815
       facial, .     .    .     .   i. 848, 811
       fibular,     .    .     .    .   i. 766
       of fore-arm,      .     .    .   i. 811
       glutaeal and ischiatic,  .    .   L 795
       femoral,    .     .     .    L 777, 901
       of the hand,     .     .    L 808,  90
       head, external arteries of, i. 844, 951
       internal iliac,    .     .    i. 792, 904
       intercostal,      .     L 889,  iii. 190
       internal mammary,    .    .   i. 889
       lingual.....i. 849
       meningeal,  .     .     .     .  ii. 513
       occipital,   .    .     .    .   L 848
       of penis,   .    .     .    .   i. 890
       plantar,    .    .     .    .   i. 907
       pharyngeal,      .     .    .   i. 851
       posterior tibial,  .     .   L 764, 907
       popliteal,   .    .     .   i. 769, 907
       subclavian,   i. 831—842, 896—951,
                             956, 962—966
       first case of ligature of left sub-
          clavian artery within  the
          scaleni muscles,     .     .   i. 835
       tables of ligature of the subclav-
          ian artety within the scaleni, L 837
       thyroid,     .    .    .    .  i. 850
       temporal,    .    .     .    .  i. 848
       vertebral,                 .   L 852
          see Aneurisms, also remarks
          upon  aneurism and cases of
          operations  upon  arteries.
            Appendix,  .     .    .  L lvL
                                     PAG!
Arsenical caustic,  .    .         • & 69'
Arteriotomy,.....■   q*
Articulations, anchyloses of,  .     .  \ 484
       artificial or supplementary, .  i.  48
       excision of,      .    .     . iL 440
       excision  of abnominal—Ap-
         pendix,  .    .    •     •  i- li*-
       foreign bodies in,     .    . iL 751
       supplementary or artificial, in
         cases of anchyloses,       .  i. 489
       exsection of,    .    .    . iL 440
Articulations in particular,
       of elbow,   .    .    .     . ii. 451
       statistics of exsection of elbow-
         joint,      .    .    •    • ii. 456
       of the hand,     .    •    . ii. 443
       of the knee-joint,     .    .  i. 490
       of the metacarpal bones,     ii. 444
       tibio, tarsal, its exsection,    iL 486
       thumb, of the first phalanx,  ii. 443
       of the wrist-joint,     .     . iL 447
         see Exsections.
 Articular tumors,   .     .    .     .  ii. 689
 Articulated or chain saw,     .     .  ii. 282
 Artificial anus, anaplasty for,      .  i. 619
       anus, operations for, and cases
         of,   i. 619,  iii. 297, 353, 762, 836
        anus, after crural  hernia, an
         operation to remedy it,    iii. 905
        cataract,   .     .     .     .  ii. 885
        eyes,.....ii. 910
       joints, or articulations,      .   L 489
        limbs,.....ii. 276
        pupil, .    .     .    _.     .  iL 886
          improved by artificial stra-
            bismus,     .     .     .   i. 548
 Ascites, tapping for,     .     .     .iiL 195
        acupuncture   in — see   Ap-
          pendix L, p. lxiii.
 Assistants in surgical operations,     i.  16
 Astragalus, exsection of,        ii. 425, 484
 Atheromatous tumors,  .     .     .  ii. 763
 Atmosphere, its action on wounds,   i. 229
 Atresia of the meatus auditorius ex-
          ternus,   .    .     .     . iii. 101
        of the mouth,    .     .     . iiL  19
        of  the os uteri,  .     .     . iii. 913
 Auditory  apparatus, operations on, iiL 100
        meatus, its deformities,     . iiL 107
 Aural diseases,    .     .     .     . iii. 100
          see Ear.
        polypus,    .     .     .iiL 106, 928
 Autoplasty—see Anaplasty,  .     .  L 550
 Avulsion of the arm and scapula,    iL 188
 Axillary aneurisms,     .     .   L 898, 951
          compression  on  the distal
            side of,     .     .     .   i. 707
        artery, compression of,      .   i. 684
          ligature of,       L 825, 898, 951
 Axilla,  bandages for,    .     .  L 165—1?4
        lymphatic tumors of, .     .  ii. 593
        tenotomy, or division of the
          tendons of axilla,   .       i. 442

                    B
 Balls of hair in the rectum,   .     . iii. 769
 Ball of the eye, operations on,     .  iL 837 
960
INDEX.
Back,  subcutaneous division  of its
         muscles and tendons,     .  L 473
         see Tenotomy.
       musket,  &c.—see  Gunshot
Balls,
         wounds, .
Balls as foreign bodies,  .
Balls passing through the brain w
         out causing death,
th-
      for bleeding,
      calico or muslin, .
      caoutchouc,
      circular,
      compressing,
      containing,  .
      dextrine,
      dividing,
      in general,  .
      glutinous,   .
      linen,
      pocket handkerchiefs used as
         bandages,     .     .     .   i.  191
      ribbon,     .     .     .     .   i.  120
      roller,.....i.  140
      rules for applying bandages    L  146
      square bandages, .     .     .   i.  149
      starch,     .     .     .     .   L  123
      T bandages,     .     .     .   i.  148
      tail,.....L  146
      triangular,       .     .     .   L  149
      thread,     .....i.  120
      uniting,    .     .    .     .   i.  163
      wet,.....i.  122
      woolen,    .     .     .     .   i.  118
  Particular bandages for certain re-
         gions,                   .   L  153
Bandages for abdomen, .    .   L 169,  195
      amputation,     .     .     .   L  196
      anus and perinaeum,   .    .   i.  176
      axilla,.....L  194
      chin......i.  159
      cranium,    .     .    .     .   L  153
      ear,.....L  160
      eyes,.....L  156
      face,                  .   i. 156,  192
      fore-arm,   .     .    .     .   i.  185
      fractures,   .     .     .   i. 182,  199
      fractures  and   lixations  of
         clavicle,  .     .     .     .   i.  185
      fractures of the head,  .     .   i.  185
      fractures of the fore-arm,    .   i.  185
      fractures of the  humerus,    .   L  184
      fractures of the ribs and ster-
         num,
      for the genital organs,
      hand,  .    .
73, 531
 iL 747
i. 531
L 116
i. 239
L 118
   ib.
i. 139
i. 139
i. 138
i. 123
i. 163
L 137
i. 122
L 117
head,  .
hernia,
lips and chin,
lower extremities,
lower jaw,  .
mask,  .
neck,  .
nose,  .
pelvis,
perinaeum and anus,
scrotum,
153,
  i. 187
  i. 171
  L 180
164, 191
  i. 200
  i. 159
  i. 182
  i. 192
  i. 169
163, 198
  L 158
  i. 196
  i. 176
  i 173
                                     rioa
Bandages—continued.
      thorax,     .     .     .   L 166, 196
      uniting bandages,     .     .   i. 199
      upper extremities,     .     .   L 180
Bands,......i. 116
Basilar artery, aneurism of,   .     .   i. 853
Basilic vein, bleeding in,     .     .   i. 237
      artery, wound of in venesec-
         tion.....L 252
Baths,......i. 228
      in reduction of hernia,      . iii. 246
Beds, surgical,     .     .     .     .   L 134
Belladonna and hyoscyamus in her-
         nia,      .... iii. 251
Belly, lower, operations upon,     . iii. 195
Bend of the arm,  tenotomy of,     .   L 440
Biceps cubiti, division of its tendon,   L 413
       tenotomy  of,                  i. 440
Bilateral operation of lithotomy,   . iii. 587
         see Lithotomy.
Bird pock, punctures,   .     .     .   i. 270
Birth-marks, or naevi materni,     .  ii. 653
Bistoury, manner of holding,  .     .   L 288
Bites of rabid animals, amputation
         for,                     .   iL  82
Bladder, bi-lateral operation for stone
         in the,   .... iii. 587
       calculi of the,    .     .     . iii. 660
       cancer of  the,   .     .     .  ii. 712
       extraction  of foreign bodies
         from the,     .     .     . iii. 840
       foreign bodies in,     .     . iii. 750
         how extracted,     .     . iii. 820
       injections of the, .    .     .   L 222
       injection of, after lithotomy, iii. 604
       puncture of the,  .  iiL 743, 820, 838
       puncture of perinaeal,  .     . iii. 743
       accidents from perinaeal punc-
         ture,     .    .     .     . iiL 605
       puncture of, through the rec-
         tum,     .... iiL 745
       puncture of the, in hypogas-
         trium,   .    .    .     .iii. 746
       puncture through  symphysis
         pulvis,   .    .    .     .iiL 748
Bleeding, or venesection,     .   l 236, 240
       at the arm, ...     .  L 236
       arteriotomy,     .    .    .  i. 263
       birds peck, punctures, .     .  L 270
       cupping,   .    .    .     .   L 273
       difficulties in,   .    .    .   L 245
       foot, bleeding in,     .    .  i. 258
       local......i. 264
       by leeches,     .    .    .   L 265
       how arrested,   .    .    .   i. 267
       in the neck,      .    .    .   L 254
       in mortification, .    .    .  ii. 128
      in reduction  of strangulated
        hernia,   .     .     .     .iii. 247
Blepnaroplasty, or anaplasty of the
        eyelids,             .   L 585, 636
           see Appendix,    .    L xliv.
      in America, .     .     .     .   L 590
Blepharoptosis,    .     .     .     .  ii. 820
Blisters,.....i. 280
      in mortification,  .     .     .  ii. 128
      in synovial cysts,     .     .  ii. 664 
INDEX.
961
                                      PAOE
 Blood drawn from veins,     .    .  L 261
        its course, how arrested in am-
          putations,     .    .    .  ii.   3
        how to arrest the course of,    L  20
          after operations,    .    .  i.  42
        vessels—see Arteries, .    .  i. 662
             also veins,  .    .    .  iL  34
        vessels of a limb how changed
          after ligature of main trunk, L 748
        vessels,  lesions of—see Aneu-
          risms,    .    .    .    .  L 665
 Bloody tumors,   .     .     .     .   iL 633
 Bodies, foreign—see Foreign Bodies,  iL 734
        in the ear,  .    .    .    .iiL 103
        in trachea and larynx, .    . iii. 138
 Body bandages,   .    .    .    .  L 165
        thyroid,    .    .    .    . HL 128
 Bones, abscesses of,  trephining in,    iL 542
        aneurismal tumors of, .    .  L 781
          of arm, their exsection, ii 288, 407
        caries and exsection of,     .   iL 324
        collar bone, its exsection, in
          fracture,       .    .    .  ii. 510
            see Clavicle,.     .     .  ii. 409
        of cranium, their exsection, .   iL 324
        deviations in the body of,  .  L 497
        deformities of,   .    .    .  L 484
        erectile tumors of,     .    .  iL 518
        exfoliation of,    .     .     .   ii. 125
        exsection of, after amputation, ii. 126
        exostosis and tumors of,   .   ii. 713
        of face, excision of,    .     .   iL 327
        of fore-arm, excision of,   iL 286, 483
        of foot, excision of,    .     .   ii. 292
        of femur, exsection of, .     .   ii. 296
        of fibula,    .    .     .     .  i. 292
        of hand, exsection of,    iL 286, 402
        of humerus, exsection of,   .  iL 288
        of inferior maxillary,  excision
          of,  .     .     iL 329, 347, iii. 811
        of leg, exsection of,    .     .   ii. 292
        malar, exsection of,   .     .   ii. 327
        metacarpus, exsection of,   .   iL 542
        metatarsus, trephining, &c, of, ii. 542
        exsections of, for necrosis and
          caries,    .     .     .     .   iL 324
        sequestra of, how removed—
            see  Exsections,   .     .   iL 280
        of pelvis, exsection of,      .  ii. 298
        petrous  portion of temporal,
          how fractured, .     .     .   ii. 526
        perforation of, for anchylosis,  iii. 821
       protrusion of,  after  amputa-
          tion,      .     .     .     .  ii. 124
       radius, operation on the,   .  ii. 406
       section  of, in  amputating the
          thigh,  Ac,    .     .    .  ii. 104
       of shoulder, exsection of,    .  ii. 291
       trephining of,     .     .    .  iL 509
       tibia, exsection of,     .    .  ii. 292
       tumors of,   .     .     .    .  ii. 714
       ulcers of,   .    .     .    .  ii. 406
       un-united fractures of,.    .  ii. 298
Bony cysts,  .    .    .     .    .  iL 670
Bougies, gum clastic,   .    .    .iii. 725
       hollow,     .    .     .    . iiL 727
       lachrymal,  .    .         .  iL 800
  vol. ra.                             121
Bougies—continued.
       their use in strictures of the
         urethra,  .     .    .    . iii. 727
Braces in un-united fractures,     .  ii. 309
Brain, cancer of,  .     .    .    .  ii. 714
       compression of,   .    .    .  iL 530
       concussion of,    .    .    .  iL 523
       foreign bodies in,     .    .  iL 531
       gunshot wounds of,   .    .  ii. 531
       hernia of,   .     .    .    .  ii. 713
Brachial artery, compression of,  L 683, 699
         ligature of,     .    .   i. 820, 899
         rupture of,     .    .    .  L 825
Brasdorean method of ligating arte-
         ries  for the cure of  aneu-
         risms,    .     .    .   i. 730, 897
Breast, arteries of, .     .    .    .  iii. 174
       bandages for,     .    .    .   i. 166
       compression of,   .    .    .  iii. 170
       cancer of,        .    .    j   ii. 698
       extirpation of,    .    .    .  iii. 176
       statistics of cancer of the,   .   ii. 698
       fibrous tumors of the, .    .   ii. 699
       tumors of the,    .    .    .  iiL 170
Bronchial calcuh,  .     .    .    .  iii. 156
Bronchocele, or goitre,   .    . iii. 128, 943
       tracheotomy in cases of suffo-
         cation from goitre,  .     .  iiL 155
Bronchoplasty,  or anaplasty of  the
         larynx and trachea, .    .   L 610
Bronchitomy,      .     .     .iiL 136, 841
Bruising of arteries,     .    .    .   L  46
Bubonocele—see Inguinal hernia, . iii. 323
Burns,  operations to remove  cica-
         trices of,                .   L 641
       cases of such operations,   .   i. 658
       amputation in cases of,     .  ii.  68
         see  Anaplasty,   for  re-
         moval of deformities from
         burns,     .     .    .   i. 550, 662
Bursal tumors, treated by iodine in-
         jections,  .     .    . ii. 673, 690
Bursae mucosae enlarged,     .     .   ii. 663
Butter of antimony—see Caustics, .   L 297

                    C
Caesarean section,  .      .    .     .  iii. 911
                                   iiL 219
                                   ii  423
                                    L 361
                                   iL 310
                                    i. 497
                                    —499
                                      ib.
                                   iii. 702
                                   iii. 651
Canals, hernial,
Calcis os, exsection of,  .
Callosities and corns on the feet,
Callus, deformed, its exsection,
       excision and breaking up of)
       in badly united fractures,
Calculi, urinary, alternation of,
       crushing of—see Lithotrity,
       of the bladder,   .  iiL 560, 600, 701
       dissolved by chemical  means, iiL 701
external to the bladder,
fixed in the bladder,
statistics of urinary,
bronchial,
of kidney and ureter,
of mouth, palate, &c.
of nasal fossae,
of palate,
of prostrate gland,
ui. 691
iii. 602
iiL 703
iii. 156
iii. 691
iii.  49
iii.  88
iiL  49
iiL 694 
962
INDEX.
Calculi—continued. of rectum, .	iiL 769
of urethra, .	. iiL 694
in vaginal septum,	iii. 693
Calico bandages,	. i. 118
Camphor moxas, .	. i. 301
Cancer,.....	iii. 847
of the anus, . . iiL	805. 865
amputation for, .	ii. 77
of the breast, . iL 698, iii. 170	
of the bladder,	ii. 712
of the cervix uteri, . iiL	198, 538
of the colon,	iiL 321
enterotomy in,	ib.
of the cranium, .	ii. 757
of the eye,	ii. 905
of the eyelids,	ii. 829
deductions from many cases	
of, .	iii. 847
of the lips, .	iiL 15
of tho neck of the uterus,	iii. 498
of the nose,	iL 778
of the pelvis,	ii. 905
of the tonsils,	iii. 57
of the uterine neck,	iii. 498
of the uterus,	iii. 558
Cancerous tumors, cauterization of,	ii. 697
Cancerous and fibrous tumors,  dis-
         cussion upon them in the
         French Academy,   .    .  ii. 705
Cancerous tumors, statistics of,    .  ii. 699
Cantharides, blistering by,    .    .  L 280
       tincture of, to  ulcers  of the
         palate, &c,     .     .    .iii.   69
Canulas, lachrymal,     .    .    .   ii. 803
Caoutchouc bandage,    .     .    .  L 118
       bougies,    .     .     .    . iiL 725
Capeline bandages,      .     .    .  i. 154
Capillaries of a hmb, after ligature of
         its main arterial trunk,  .  i. 750
Care required in operations,   .    .  i.    7
Carcinoma—see Cancer,    ii.  694, iii. 847
            see Malignant disease.
Caries, amputation for,   .     .    .  iL   77
Cranium,  caries and necrosis of,  ii. 77, 772
       exsection for caries, <fec,  of,   iL 324
Carotid, aneurisms of the root of the,
         treated  by the Brasdorean,
         or distal method,    .    .  L 877
       compression of the,     .    .  i. 682
       ligature of, for erectile tumors, iL 572
       ligature of common, L 859, 897,  911,
                                 631, 950
       statistics  of  ligature  of the
         common, .     .         .  L 863
       ligated, for aneurisms of the
         arteria innomata,    .    .  L 878
       table of such operations,  i. 878, 945
       ligature of both carotids,   .  L 867
       table of such operations,   .  i. 867
       secondary, ligature of,     .  i. 857
       region, tumors of,      .    .  ii. 602
       tubercle in connection with the
         vertebral artery,     .    .  i. 682
Cartilages loose in joints,     .    .  ii. 751
Cartilaginous tumors,    .     .    . iii. 671
Caruncula lachrymalis,  .     .    .  L 529
    ib.
iii. 421
iiL 231
iii. 421
 i. 211
iii. 851
 iL 865
    ib.
iii. 852
 ii. 863
iiL 850
 iL 850
iii. 704
iii. 713
Caruncula lachrymalis—continued
       shrinking of, after tho opera-
         tion for Strabismus, .
Castration,   ....
       for radical cure of hernia,
       hemorrhage after,
Cataplasms,  ....
Cataract,     .     iL 841, 850, 884, iii. 850
       catoptric test for,     .     . iii. 851
       depression of,
       extraction of,
       solution of,
       size of pupil in,
       operation for, in children,
       statistics of,
       needles,
Catheterism, .
       in women,  .
       of bladder, in cases of stone, iiL 561
       of eustachian tube,   .     . iiL 110
       of the larynx,    .     .     . iiL 156
       of lachrymal ducts,   .     .  iL 791
       of oesophagus,    .     .     . iii. 167
       of salivary fistulas,     .     . iii.   35
       forced,      .     .     .     . iii. 714
Catheters and sounds,   .     .     .   i.   96
       flexible,     .... iii. 710
       silver,.....iii. 704
       self-retaining,     .     .     .iiL 885
       how held in the bladder,    . iii. 712
Catheter bandages, for retaining tho
         catheter in the urethra,   .   i. 170
Catgut ligatures,   .     .     .     .   i. 714
Cat tails as dressings,    .    .     .   i. 107
Catoptric test of cataract,     .     . iii. 851
Cataplasms......L 211
Caustic issues,     .     .     .     .   i. 287
Caustics, cauteries and cauterization,
         applied to aneurisms,     .   i. 707
       cervix uteri,      .    .     .iii. 500
       cancerous tumors,     .     .  iL 697
       cleft palate, .     .     .     . iii.   66
       ectropion,   .     .    .     .  ii. 815
       erectile tumors,   .   L 628, 638, 655,
                                    ii. 557
       fissures of the anus,
       fissures of the perinaeum,
       fistulas of the urethra, .
       hemorrhage from leech bites,
       hernia,      ....
       hydrocele,   ....
       Lallemand's caustic applied to
         the urethra,    .     .     . iii. 733
       of lachrymal fistulas,   .     .  ii. 807
       of the nares, for opthalmia, .  ii. 911
       of polypus of tne nose,
       of prolapsus ani, .
       of prolapsus uteri,
       of radical cure of hernia,
       of ranula,
       of rectal  fistulas, .
       recto-vaginal fistulas,
       of the rectum,
       salivary  fistulas, .
       synovial  cysts,
       to the teeth,
       tonsils,
iii. 784
iii. 544
iii. 752
 i. 267
iii. 221
iii. 385
. iiL	76
. ni.	779
. m.	465
1, . in.	221
. UL	36
. m.	767
. UL	534
. IIL	767
. in.	26
. u.	644
. i.	321
. UL	50
 
INDEX.
963
Caustics, &c.—continued.
       trichiasis,   .     .     .     .  ii. 821
       urethra,    .     .     .     .iii. 731
       uterus,     .     .     .     .iii. 466
       urethral fistulas, .     .     .  iii. 752
       urethral strictures,    .     .  iii. 731
       un-united fractures,   .     .  iL 303
       uvula,.....iiL  58
       varices,     .     .     .     .  ii.   3
       of velum palati,  .    .     .  iii.  61
       of vesico-vaginal fistulas,   .  iiL 528
       varicocele,  .     .     .     .   i.  21
Cauterization,     .     .    .     .   i. 294
Cautery actual in erectile tumors, .  iL 560
       in cancer uteri,  .     .     .iiL 500
Cavernous bodies  of the  penis, rup-
          ture of,  .     .    .     .  iii. 924
Cavity orbitar—see Orbitar cavity,  iL 834
Cavities closed.....ii. 684
Cellular hematic cysts,  .     .     .  ii. 640
Cephalic vein, bleeding from,    i. 237, 254
Cephalalgia.—see Scalp, .    .    .  L 211
Cephalematoma, or bloody tumors of
          the  cranium,  .     .     .  ii. 765
Cerate dressings,  ...     .  L 202
Cells mastoid, operation on,  .     .  iii. 110
Cerebriform cancer,     .    .     . ii. 695
Caesarean operation,    .    . iii. 548, 555
       statistics of,     .    .     .  iii. 911
Cervix uteri,  amputation of,  .     .  iii. 498
          occlusion of,   .    .     .iii. 462
Chain saw,.....ii. 282
Chalinoplasty, or restoration of fraenum
          of prepuce,     .    .    .  i. 657
Changes in the system, after amputa-
          tion,     .     .    .    . ii. 130
Cheeks,  restitution of, or genoplasty, i. 601
       unnatural adhesion  of,.     .  iii.  23
Cheiloplasty,  or restitution of the lips, i. 592,
          655—see Appendix i. L
       in cancer,  .     .    .     .  i. 638
Chemical solvents, of urinary calculi, iii. 701
Cherry-stones, &c, in the nose,    .iii.  72
Chest, bandages for the,      .     .   i. 165
       foreign bodies in,      .     .  iL 736
       operations on,   .     .     .  iii. 170
       paracentesis of,  .    .     .  ii. 857
       statistical table of cases of this
          operation,     .     .     .iii. 858
       sound,.....i.  95
Chin, bandages for the,  .     .     .   i. 150
Chloride of zinc, in erectile tumors,  ii. 558
Chloride  of zinc paste—see Caustics, i. 297
Chloroform, in surgical operations,   iii. 823
Chopart's operation on the foot,    .  iL 210
Chisel and mallet, in exsections,   .  ii. 320
Children, inguinal hernia in,  .     .  iii. 345
       hare-lip, operation in,  .     .  iiL  13
       lithotrity in,     ...  iiL 700
Chromate of potassa, moxas of,     .  i. 301
Cicatrix  from  venesection,    .     .  L 247
Cicatrices, removal of,   .     .     .  L 377
       anaplasty for,  i. 377, 608, 635, 641,
                                       698
Circular  bandages, .     .     .     .  i. 139
       method of amputation,     .  ii.  99
Circosele,.....ii.   2
Cirsoid aneurism, ligation of arteries
         in,.....". 573
Clamp sutltre,     .     .          . iii. 872
           see Vesico-vaginal fistulas.
Classification of operations,    .     .   i.    2
Clavicle, exsection of,   .     .  ii. 409,474
       remarkable case  of,  for osteo
         sarcoma, .     .     .     .  iL 410
       exsection  of a false joint in
         the......ii. 308
       fracture of, .     .     .     . iii. 889
       fracture bandages of the,    .   i.   85
       trephining of,                 ii. 547
Cleaning the teeth,      .     .     .   i. 317
Cleft palate,.....iiL   60
           see Staphyloraphy.
Climate, its effects on surgical opera-
         tions.  Appendix  i.  xlv.
       its effect on amputation,     .  iL 132
Clitoris,  diseases of,  and operations
         on the,    .     .     .iii. 446, 452
Closed cavities, or cysts,      .     .  ii. 689
Clothing, pieces of clothing acting as
         foreign bodies,      .     .  iL 748
Club-foot,     .    .     .    418—445, 501
           see Appendix i. Iii.
       tenotomy in,     .     .   L 445, 459
Coats  of arteries,   .     .     .     .   i. 662
Coccyx and sacrum, excision of,   ii. 392, 397
Cold water dressings,   .     .     .   i.   57
Collodion,.....iii. 852
Collutories, or washes for the mouth,  i. 221
Cold, as an anaesthetic,  .     .  iii. 406, 825
Collar bone, exsection of,     .  iL 409, 474
Colloid tumors,    .     .     .     .  iL 694
Common iliac arteries,   .     .   L 801, 941
Composure and presence of mind in
         surgical operators,  .     .   i.   40
Compressing bandage,   .     .     .   L 139
Compression in aneurisms,    .  i. 694—707
       of arteries,  .     .     .     .   i. 679
       of arteries, in case of wounds,  L 690
       of arteries of abdomen,      .   i. 688
       of arteries of extremities,    .   i. 683
       of head and neck,     .     .   i. 681
       in hemorrhage from the al-
         veoU,     .     .     .     .   i. 693
       in erectile tumors,     .     . ii. 553
       of the breast,     .     .     . iii. 170
       in fractures,      .     .     .  ii. 201
       in general, .     .     .     .  ii. 530
       in hernia,   .... iii. 221
       in hydrocele,     .    .    . iiL 398
       in hypertropy of tongue,    . iii.  48
       in synovial cysts,     .    . ii. 664
       in varices,  .     .     .     . ii.  12
       in salivary fistulas    .    . iii.  26
       of the brain,     .    .    . ii. 530
       in surgical operations to arrest
         flow of blood in the diseased
         part.....i.  20
       after operations,   .     .     .  i.  46
Compound fractures,  exsection of, . ii. 283
Conservative surgery, in saving  limbs
         from amputation,    .    . ii. 271
Collodion,.....ui. 850
Concussion,.....ii. 523 
964
INDEX.
 Conjunctiva, ectropion, from exuber-
          ance of,  .    .     .    .  ii. 816
 Conditions accessory to operation!, i. 16—61
 Condyles of humerus, fracture of,  . iii. 891
 Congelation  of  limbs,  amputation
          for,.....iL  67
 Congenital hernia, .... hi. 327
        cohesion of parts,     .    .  L 397
        hydrocele.....iii. 403
        luxations,   .     .     .    .  Ui. 855
 Conical stumps,   .     .     .    .iii. 123
 Conservative  surgery,  in   saving
          limbs,    .     .     .    .  ii. 271
 Consequences of operations,  .    .   L  62
 Consumption, fistula in ano, with,  .  iii. 803
 Containing bandages,   .     .    .   L 138
 Continuity, amputation in,    .    .  ii.  99
 Contiguity, amputation in,    .     .  iL 108
 Contraction of the anus and rectum,  iii. 765
        of the aorta,      .     .    .   i. 806
        of meatus of the urethra,    .  iii. 730
        of the cesophagus,     .    .  iii. 159
        of the urethra,   .     .     .  iii. 714
            see Strictures of the urethra.
 Convulsions during operations,     .   i.  27
 Coretomia,.....ii. 887
 Coredialysis,.....ii. 891
 Cord, spermatic, in hernia,    .     . iii. 333
            see Hernia.
       Spermatic, hydrocele of the,. iii. 406
 Cornea, abrasion of, in cases of opac-
         ity,  .....ii. 911
       growths upon  the,     .    .  ii. 839
       horny  plates of,   .     .     .  iL 859
       transplanting of, .     .   i. 591, 635
 Corns and warts,  .    .     .     .  i. 359
 Corpus cavernosum penis, laceration,
         or fracture of,  .     .    . iii. 924
 Cotton as a dressing,    .     .     .  i. 107
 Couching in cataract,   .     .     .  iL 850
 Cough impulse, in strangulated her-
         nia,  .....iii. 905
Court plaster,     .    .     .    .  L 207
Coverings of hernia,    .     .    . iiL 215
Cranial sutures, their separation with
         fracture,  .    .     .    .  ii. 536
Cranium, arteries of the interior,   .  i. 845
       anaplasty of,     .     .     .  L 570
       abscesses of,     .     .    .  iL 773
       aneurism within,      .    .  i. 845
       bandages for,     .     .   i.  153, 191
       exsection of bones ©f the,  iL 324,
                                      333
       cancers of,  .     .     .    .  ii. 757
       caries and necrosis of,  .    .  ii. 772
       depression   of,  relieved  by
         cupping,  .     .     .    .  h. 537
       effusions  in,     .     .    .  ii. 510
       encephalocele of, .    .    .  iL 762
       exostoses of,     .    .    .  ii. 716
       exsection of bones of)  .    . iiL 323
      fibrous tumors of,     .    .  ii. 755
      fungous tumors of)     .    .  ii.  ib.
      fungus  of dura  mater,  .    .  iL  ib.
      foreign bodies in,     . ii. 531, 774
      fractures of,      .     . iL 510, 524
        statistics of)    .     .    .  ii. 537
Cranium—continued.
      abscess of the liver from frac-
         ture of the,    .     .     . ii. 532
      fracture of petrous portion of
         temporal bone of,   .     .  ii. 626
      frontal sinus, operations of, on, ii. 771
      hematic or sanguineous tumors
of the, . . ii	. 765, 769, 956
hernia cerebri, . . . ii. 762	
hydrocephalus, . . . ii. 765	
meliceris of scalp, . . ii. 762	
nerves of scalp, . . . ii. 89	
operations on the, . . ii. 755	
sanguineous tumors of the, . ii. 769	
sinus frontal, . . . ii. 771	
trephining of) . . ii. 509	
statistics of trephining opera-	
tions, . . . . iL 512	
vegetations of the dura mater,	
&c......iL 766	
Cremaster muscle—see Inguinal her-	
nia, .....iii. 333	
Cross of Malta, . . . . i. 114	
Cricoidean laryngotomy, . . iii. 149	
Crow-bar passing through the brain,	
recovery from, . . . ii. 531	
Crystalline lens, opacity of) . . ii. 841	
ossification of, . . ii. 884	
see Cataract.	
Croup, tracheotomy for, . iii. 140, 160, 846	
in adults, . . . .iiL 152	
Croton oil, in erectile tumors, . ii. 656	
Crural canal,.....iiL 355	
complicated case of crural	
hernia, . . . . ui. 364	
hernia—see Femoral hernia, iiL 354	
nerve anterior, neuromas of) ii. 616	
operation for strangulated cru-	
ral hernia, . . . UL 359	
relation of the epigastric artery	
to crural hernia, . . Ui. 356	
strangulated crural hernia, . iiL 368	
Crushing of arteries, . . . L 708	
of erectile tumors, . . u. 565	
of lymphatic tumors, . . U 585	
of synovial cysts,. . . iL 665	
of sanguineous tumors, . u. 683	
Cupping in depression of the skull, iL 537	
glasses, . . . . L 273	
Cure, radical, of hernia, . . . iiL 220	
spontaneous, of aneurisms, . L 775	
Cushions in dressings . . . i. 130	
Cutaneous nerves, operations upon, ii. 50	
irritations, rubefacients, Ac, i. 276	
tumors, . . . . U. 550	
Cutting forceps,	. iL 281
instruments,	. L 327
Cystitis after amputations,	. u. 129
Cysts, ....	. ii. 639
of abdomen,	. iii. 195
hematic,	. iL 647
lachrymal, .	. u. 786
sebaceous, .	. iii. 195
serous,	. ii. 659
Synovial,	. ii. 662
Osseous,	. iL 670
of female organs, .	. UL451
 
INDEX.
965
Cysts—continued.
       ovarium,
       of the liver,.
       of lower belly,
       of thyroid gland,
iiL 208
 ii. 207
iii. 208
iii. 943
sanguineous, of the female ex-
  ternal organs of generation,
                            Ui. 451
Dartos muscle—see Hernia and In-
         guinal hernia, .     .     .iii 332
Dead body, operations upon the,   .   i.   5
Deformed leg from fractures success-
         fully treated,  .     .     .  iL 312
Deer-skin Ugatures,     .    .    .  i. 715
Deformed callus, treatment for,     .  ii. 311
Deformities, amputation for,  .     .  ii.  83
       removal  of,      .      L 377, ii.  83
       from alteration of ligaments,   i. 481
       of tendons or muscles,    i. 399—474
       of the skeleton,   .      i. 484—500
       from cicatrices of burns,   L 377, 658
       from  the auditory  meatus,   ii. 312,
                                   Ui. 101
       see also anaplasty,     .     .   i. 588
       ankylosis and cicatrices, L 484, iii. 819
       and tenotomy,   .    i.  501, iii. 942
Dental operations, .    .     .     .  L 316
       nerves,     .    .     .     .  ii.  42
       border of lower jaw, its re-
         moval,   .    .     .     .iii. 343
Dessault's bandage,     .     .     .   L 185
Destroyed parts, their restoration, .   L 550
Depression of cataract,  .    U. 850, Ui. 857
       of the skull, cupping in,     .  ii. 537
Depressor of the tongue,     .     . iii.  52
           see Tonsus.
Dextrine bandages,     .     .     .  i. 123
Diachylon, or adhesive plaster,     .   i. 127
Diagnosis of sub-sternal aneurisms,    L 878
       of fractures by the stethoscope,
                                  in. 333
                                   iL 671
                                    i. 747
                                   ii. 689
                                  iii. 373
                                    i.  63
                                  UL 545
       of inguinal hernia,
Diaphragm, osseous plate of)
Diathesis, hemorrhagic,
Diathesis strumous,
Diaphragmatic hernia,   .
Diet, after operations,
Difficult labor,
           see Dystochia.
       rupture of the uterus, in,   . UL 555
Diffused false aneurism, case of)   .  i. 962
Dilatation of the lachrymal ducts,  .  ii. 794
       of the urethra,    . Ui. 724, 743, 940
       of the rectum,    .    .    . iu. 765
Diplopia, or double vision, after the
         operation for strabismus,    i. 543
Director, or grooved sound, .	. L 97
Disarticulation of the foot,	. u. 215
of the metatarsus,	. u. 199
of tho scapula,	. iL 188
of the tarsus,	. u. 207
Dislocations, ....	. iu. 853
amputation in cases of)	. ii. 69
anaesthesia in reducing,	. iiL 855
congenital, of the femur,	. UL 853
new mode of reducing,	. Ui. 854
&c,
plasters,
strips, adhesive,
after operations,
precaution in,
removal of first,
treatment of wounds at
after amputation,
  of the penis,  .
of ligature of arteries,
in lithotomy,
of fistulas La ano,
.   i. 343
.   L  86
730, 897

.   i. 114
.   i. 163
.   L   1
i. 473
i. 685
L757
i. 756
i. 103
per
L  28

L-527
L 635
i. 284
L 292
L293
Dislocations—continued.
       twisted  rope, used in  reduc-
         ing, .....iii. 854
Dissection of tumors and cysts,
Dissecting wounds,
Distal operation for aneurism,
           see Aneurisms.
Divided compress, .
       bandage,
Division of this work,
       of the fraenum of the prepuce, iii. 444
Double encysted tumor, removal of,  u. 689
Dorsal myotomy,  .
Dorsalis pedis, compression of,
         ligature of)
         wounds of)
Dossils of lint,
Double operations,  or those
         formed at two times,
       vision, after the operation  for
         strabismus,
       strabismus, .
Drains, as issues, setons, &c,
       accidents from,
       suppression of)
Dressings  and instruments required
         in operations,
Dressing, the art of,
       instruments required in,
Dressings, various kinds of)
       adhesive strips for,
       for amputation,   .
       baths, .
       cataplasms, .
       cold water, .
       collutories, .
       court plaster,
       douches,
       embrooations,
       enemata,
       fomentations,
       fumigations,
       gargles,
       precautions in,
       of wounds after some hours,
         at first,
         at long intervals,
       hours for,
       hot air in,  .
       intervals of)
       injections,  .
       immovable, in fractures,
       of irrigations,
       Uquids, various,
       liniments,  .
first.
   L  17
   i.  89
    i.  90
   i. 202
   i. 206
   ii.   3
   i. 228
   i. 211
   i.  57
   L 221
   L 207
   i. 227
   L220
   i. 224
   i. 220
   i. 221
   i. 220
   i. 229
   L  45
   i. 230
   L 232
   L 232
219, 229
   L 233
   i. 222
  U 300
   i. 216
   L 215
   L 219
   i. 203
   i. 205
   i. 207
   i.  52
   i. 229
   i. 231
   L 230
  u. 116
 iii. 449
   L742
 iii. 633
 iii 804 
966
INDEX.
Dressing—continued.
       of fistulas vesico-vaginal,   . iii. 886
       of tapping in ascites,  .     . iii. 200
Dropsy, abdominal, or ascites,     . Ui. 195
       ovarian,     .... iii. 208
       of pericardium,  .     .     . iiL 192
       of thorax,  .... Ui. 181
Duct, lachrymal, fistulas of,  .     . ii. 786
       of Stenon,   .    .     .     . Ui.  29
       of submaxillary  gland,  ob-
         struction of—see  Ranula,   iii.  33
Dura mater, cancers of, .     .     . ii. 757
       fibrous tumors of)     .     . ii. 755
       fungous tumors of,     .     . U. 755
       hematic tumors of)     .     . ii. 756
       vegetations of,   .     .     . ii. 756
Dystochia, or difficult labor,  .     . iii. 545
       symphysiotomy, .     .     . iii. 545
       Caesarean section,     .     . iii. 548
       vaginal uterotomy,    .     . iii. 554

                    E
Ear, external, anaplasty of,  .     .  L 571
         bandages for,  .     .     .  i. 160
         diseases of,    .     .     . iii. 100
       foreign bodies in the,  .     . iii 102
       hemorrhage  from the, in frac-
         tures of the temporal bone, U. 526
       operations on the,     .     . iii. 100
       internal, diseases of)  .     . iiL 108
       lobe of, its perforation,     .  i. 313
         polypi of the,      i. 108, iiL 928
       perforation  of the  membrana
         tympani,    .     .    .  . UL 108
       Berous discharge from the, in
         fractures  of  the  petrous
         portion,  .    .     .     . ii. 527
Ecchymosis,.....i. 248
Ectropion,.....ii. 815
Effusions into the abdomen,  .     . iii. 195
       into the cranium,     .     . ii. 510
       into the serous cavities from
         purulent infection,  .     .  L  78
       into the thorax, .     .     . Ui. 179
Elbow, anchylosis of)        .     .  i. 489
       division of the Ugaments of,   i. 476
       division of the nerves of,   . U  50
       divisions of the tendons of, .  i. 413
exsection of)
i. 489, U. 457
       exsection of, partially, .     .  U. 458
       statistical table of exsections
         of the,    .    .    .     .  u. 486
       Ugature of arteries of the,   .   L 815
       tenotomy of the, .    .     .   i. 440
Elephantiasis  Arabum,  Ugature  of
         arteries in,
       of male genital  organs,
       of female genital organs,
Elephantine tumors,
         of the nose,
Electro puncture,  .
         in aneurisms,  .
Elevator of the teeth,
Elytroplasty,  or  anaplasty of  the
         vagina,
Embrocations,
 i. 782
ii. 631,
iii. 418
iii. 454
 ii. 631
 iL 779
 ii.  55
 i. 711
  L325

  i. 624
  L220
                                     PAQB
Emphysema of the eyeUds,   .     .  iii. 856
Empyema of the eye,   .     .     .  U 901
       of the thorax,    .  iu. 179, 187, 856
         Appendix i. lxii.
       statistical table of tho opera-
         tions for,      .     . iii. 183, 858
       see  Paacentesis of thorax,  iU. 187,
                                      858
Encanthis,.....ii 832
Encephalocelc,    .    .    .   ii 762, 713
Encephaloid tumors,    .     .     .  ii. 694
Enchondroma,     .    .    .     .  ii. 671
Encysted hydrocele,    .     .     .  ii. 408
       enormous tumors,     .     .  iL 690
       tumors of the female labia, .  iii. 451
Enemata,                    iL 224,  iU. 248
       in hernia,   ....  iii. 248
English lint,.....i. 106
Enlarged tonsils,   ....  UL  49
Entero-vaginal fistulas, .     .     .  Ui. 537
Enterotomy,      .  iii. 300, 321, 852, 862
       remarkable cases of,   .     .  iiL 321
Enterocele—see hernia,   Ui. 253, 300, 319,
                                      323
Entrance of air into the veins,     .   L  30
Entropiop,.....ii 823
Envelops of hernia,     .    .  iu. 215, 332
Epicanthis,.....ii. 853
Epigastric artery, its relation to crural
         hernia,   .    .     .     .  Ui. 356
       artery,  wounds of in inguinal
         hernia,   .    .    .     .iii. 350
Epiplocele,   .    .    . UL 232, 239, 270
Epilepsy,  tracheotomy for,   .     .  iiL 843
Epiphora,.....iii. 866
Episcoraphy, or episcoplasty, or  su-
         ture  of the female labia,  .   i. 644
Epispadias,.....Ui. 867
Epistaxis,.....iii.  74
ErectUe tumors, their treatment by
           red hot needles,  .     .  u. 580
         ligature of arteries in,     .  U. 570
         ligature of carotid, for,   .   i. 870
         of the eyelids, .     .     .  ii. 829
         of the orbit,   .    .     .  u. 567
         removal  of,  u. 553, 575, 580, 583
         of the scrotum—Appendix,
         vol. L Ui.
         of the vulva,  .    .     .  iiL 451
           Appendix, vol. i. lxi.
Erysipelas,                  i. 67, 703, 746
       treatment of)    .    .     L 67—75
       use of sulphate of iron in,  .   i.  67
       leeches in,  .    .    .     .   i.  73
       plegmonous,     .    .     .  i. 73
       suppurative,     .    .    .   L  73
       after venesection,     .    .    i. 250
Ether and chloroform  in  surgical
         operations,    .    .    .  iii. 822
       sulphuric as an anaesthetic, in
         surgical operations, .     .  iii. 822
       see also Chloroform,  .     .  iii. 823
Eustachian tube,   .    .    .     .  iii. 110
Eversion of the lips,    .    .     .  iii.  17
Exfoliation of bones  after amputa-
         tion,      .    .    .     .  ii. 125
Exomphalos, ...          .  Ui 365 
INDEX.
967
                                     PAQI
Exostosis, or tumor of bones,      .  ii 714
       of the cranium,  .    .    .  ii 714
       of the face,  .    .    .    .  ii 717
       of the femur,    .     .    .  ii. 723
       of the foot,  .    .    .    •  ii- 721
       of the fore-arm,  .    .    .  u. 720
       of the hand,     .    .    .  ii 719
       of the humerus,  .    .    .  U. 720
       of the leg,   .    .    .    .  ii. 721
       of the limbs,    .    .  ii 719, 726
       ofthepateUa,   .    .    .  ii 723
       of the pelvis,    .    .    .  ii. 718
       of the scapula,   .    .    ,  ii. 721
       of the sternum,  .     .    .  iL 718
       of the toes,  .     .     .    .  L 375
       of the vertebrae,  .     .    .  iL 718
Exploring needles  and punctures, .   L 347
Exsection, or excision of bones,   .  iii. 280
       of the  acromial  end  of the
         clavicle,  .     .     .    .  iL 475
       in cases of anchylosis,  .    .  L 485
       of the articulations,    .    . iL 440
            see Articulations.
       of the astragulas,.     .  iL 425, 484
       of the ankle-joint,      .    .  ii. 486
       of bones of the arm,   .    .   ii. 407
       of articulations,   .     .    .  ii 440
       of the breast,     .      iU 498—507
       of callus, deformed,    .    .  ii. 310
       of caries,    .     .     .    .  iL 324
       of clavicle,  .     .     .  iL 474, 409
       of clitoris,   .     .     .    . iiL 452
       of cicatrices,    .     .    .   L 378
       of compound fractures,     .  n. 285
       of un-united fractures,     .  iL 298
       of coccyx and sacrum,  ii. 392—400
       of cranial and facial bones, ii. 324—
                                      375
       dressings after,   .     .    .  ii. 283
       of elbow,    .     .     L489, ii. 451
       eye......ii. 902
       of bones of face,  .     .  u. 324, 375
       of false joints,    .     .    .  iL 362
       of femur,   u. 296, 305,309, 434, 604
       of fibula,    .     .     .   ii 294, 431
       of fistulas in ano, .     .    . UL 797
       of fissures of the anus,.    . UL 787
       of bones of fore-arm,
       of bones of the foot,
       of bones of the hand,
       of hemorrhoids, .
       of bones of the  humerus,
of hydrocele,
of intestines, very remarkable
U. 286, 403
iL 423, 478
   .  ii. 286
  . iiL 772
    ii. 288,
       465
    iU. 388
  case of)
of ilium,
of ischium,  .
of jaw, lower,
cases of its,
           iii. 321
, •   .    .  iL 399
         .  ii. 398
 i. 478, u. 325, 375
         .   iL 347
statistical table of operations
  on the lower jaw,   .     .  iL 339
of jaw, upper,    .     . ii. 375—-389
of knee-joint,      i. 490, U. 241, 490
of larynx and trachea, .     .  ii. 389
of leg, .     .     .     .  iL 292, 426
of malleoli  .     .     .     .  iL 429
Exsection—continued.
       of metatarsus,
       for necrosis,
       of nerves,   .
       of neck of uterus,
       of nymphae,
       of olecranon,
     iL 423, 478
        .  ii. 324
iL 39, 56, ui. 213
        . iii. 501
        . Ui. 443
        .  U.405
      on account of organic lesions,
        as caries, <fec, .    .    .  ii. 324
      of os calcis, .    .    .    .  ii- 423
      of ovarian tumors,     .  UL 212, 922
      of parts of the pelvis,  .     .   u. 397
      of parotid gland, .    . Ui. 119, 127
      of patella,  .    .    .    .  ii. 502
      of polypi of ear,  .    .    . UL 106
      of polypi of nose,     .    . UL  76
      of polypi of uterus,    .     .  Ui. 478
      of pseudarthrosis,     .     .   U. 302
      of pubes,   .    .    .    .   ii. 400
      of radius,  .    .    .  U.406, 460
      of ranula,                 iL 36—38
      of ribs,     .    .    .    .  iL 393
      of sacrum, .    .    .    .  iL 392
      of scapula,  .                 ii. 418
      of shoulder,      .     .  iL 294, 466
      of sternum,  .    .    .    .  U. 390
      of sternal end of clavicle,    .  u. 476
      of scrotum, its partial excision
        for varicocele,  .     .     .  L  33
      of thyroid gland, .     .    .  iiL 132
      of tibia,     .    .    .    .  U. 292
      of tarsus,  .    .    .  ii. 423, 481
Excision of parts of thoracic, or  the
        upper extremities,   .    .  u. 400
      of tonsils,   .     .     .   UL 51, 945
      of trochanter major,  .     .  u. 435
      of ulna,              .  u. 406, 460
      of urethra, in the female,   .  iii. 558
      of uterus,   .     .     .  UL 835, 848
      of uterine neck,  .     .     .  Ui. 502
      of uterine polypi      •     •  iii. 888
      of un-united fracture,  .    .  u. 298
      of the uvula,     .     .     . UL  67
      of vagina, partially,   .     . ui. 467
      of varices,  .    .     .     . iL    4
      of vertebrae.....U. 391
           see Extirpation  and Ex-
             traction.
Exomphalos, or umbilical  hernia,   .  UL 365
Exopthalmia, after the operation, for
         strabismus,    .     .     . L 528
Exostoses,.....U. 714
External ear, operations upon,     .  UL 100
      Uiac artery,     L 785, 905, 941, 953
      inguinal hernia,  .     .     .  UL 324
                                   u.  61
                                   L849
saphenous nerves,
maxillary artery, .
violence, amputation in cases
of,
Extirpation, of the anus,
      of cancers of the anus,
      of bloody tumors,
      of breast,
      of cutaneous tumors,
      of cicatrices,
      of cartilaginous tumors,
      of clitoris,  .
   .  u.  63
   .  UL 777
   .  iii. 807
   .  iL 636
iiL 176, 498
   .  U. 550
   .   L380
   .  a 671
   .  iii. 452 
968
INDEX.
 Extirpation—continued.
       of elephantine tumors, .    . U. 631
       of encysted tumors,   ,    . ii. 690
       of erectile tumors,    .    . ii. 676
       of erectile tumors of the eye, U. 903
       of fatty tumors,  .    .    . ii. 622
       of fibrous tumors,     .     . ii. 691
       of hematic tumors,    .  ii.  635, 650
       of hemorrhoids,  .    .    . Ui. 772
       of lower jaw,   L 478,  iL 331, 324—
                                      375
       of upper jaw,    ,    .  U. 375, 389
       of knee-joint,    . i. 490, U. 241, 490
       of lachrymal gland,   .    . ii. 815
       of lipomas, or fatty tumors,   U. 622
       of lips,     .... iii.  15
       of lower jaw, i. 478, ii.  324, 331, 375
       of lymphatic tumors, ii. 686, iii. 827
       of mammary gland,    UL 176, 498,
                                      507
       of neuromas,     .     .     .  ii. 611
       of nymphae,      .     .    . Ui. 443
       of osseous tumors or cysts,  . iL 671
       of ovarian tumors or cysts,  iii. 210,
                                      922
       of parotid gland, and of parotid
         tumors,  .     . ui. 115—127, 598
       Of penis,    ,    .    ,    . Ui. 446
       of prolapsus ani, .    .    . Ui. 776
       of radius,    ....  ii. 460
       of ranula,             ,   Ui. 38, 929
       of subcutaneous hidles,      . i. 384
       of synovial cysts, ,    .    . ii. 669
       of thyrpid gland, .    .    .  iii. 132
       of testicle,  .     .     .    .  iii. 421
       of tonsils,   .     .   Ui. 51—66,945
       of tongue,  ....  iii.  44
       ulna, entire,      ,    .    .  ii. 460
       of uterus,   Ui. 502—608, 557, 835,
                                      848
       of uvula,    .... iii.  57
       of varices,  .     .     ,    .  U.   4
           see Excisions and Amputations.
Extra articular exsections,  .    .  ii. 281
       uterine foetus, extraption  of,  Ui. 866
Extraction of balls,     .    .    .  U. 749
       of cataract.....ii. 865
      of foreign  bodies from  the
         bladder,  .     .    .    .iii 840
       of foreign  bodies from  the
         larynx and trachea, .    . Ui. 138
       of foreign  bodies from  the
         cesophagus,    .    .    162,  168
       from the  stomach  and  intes-
         tines,     .     •    ii. 736, iii. 866
       from the rectum,     .    . Ui. 768
           see Foreign bodies.
Extremities, lower, amputation of)   ii. 193
         artificial joints in,  .    .  i. 490
         bandages for,  .    .    .  i 196
         bandages  for fractures of
           the,    .    .     .   .  i 181
         bandages  for exsection of
           the,    .    .     .    .  ii. 423
         bandages for trephining of) ii. 542
       upper, amputation of,      .  ii  136
         of artificial joints in,.    .  i 490
                                     Pi.01
Extremities—continued.
         exsection of,   ,     .     .  ii. 400
         bandages for,  ,     .     .  i. 180
      bandages  for  fractures   of
           lower,  .     .     .     .  i. 187
      exsection of fractures in,    .  ii. 476
Eye, action of its oblique muscles—
         Appendix L xxvUi.
      aponeurosis of its muscles,  .  i 610
      artificial,    .     .     .     •  ii 910
      bandages,   ,     .     .     .  i 156
      cancer of the,    .     .     ,  ii. 905
      cataract in the,   .     .     .  U. 846
      diseases of and operations on
         the, .         ...  U. 837
      extirpation of the,     ,     .  U. 903
      fascia  of the,     .     .     ,  L 610
      foreign bodies in the, ii 837,  iiL 186
      muscles of the,   .     .     .  i. 508
      nerves of the,    .     .     .  L 508
      vessels of the,    .     .     .  i. 608
      opthalmoscope,   .     .     .  iii. 922
      speculum,   .     .     .     .  i. 607
Eyelashes, inversion of, .     .     ,  U. 821
EyeUds, emphysema of, .     ,     ,  iii. 856
      operations on,        .     .  U. 815
      anaplasty of)     .     .   i. 585, 636
Eye, puncture of,  ,     ,     .     .  iL 898
      section  of muscles  of)  for
           strabismus,  .     .     .  i. 511
         for other diseases of the,  .  i. 545
      excision of the,   .     .     ,  U. 902
      extirpation of the,     .     ,  u. 904
Face, bandages for the, .     .  i. 156—192
       cartilaginous tumors of the, .  ii. 672
       excision of bones of,   .     .  u. 327
       exostosis of)     .     .     .  U. 717
       foreign bodies in the,  .     .  Ui. 735
Facial artery, compression of) .     .   L 682
         ligature of,    .     ,        i. 848
       nerve, or portio dura,  .     .  ii.  45
Fainting during operations,   .     .   i.  27
Falling of  the  anus, or prolapsus
         ani,       .    ,     .     .  Ui. 775
       of the womb—see Uterus, .  iii. 465
False  aneurisms of brachial  artery
         from venesection,   .     .   L 899
           see Aneurisms.
False anchylosis of the,  lower jaw, iii. 21,
                                      819
       cartilages in the joints,     .  U. 751
       joints, pseudarthrosis,  .     .  U. 304
         exsection of,        ,     ,  U. 302
           see Exsections.
Fascia of the eye,  ....   i. 510
Fatty tumors,      .    .     .     .  ii. 619
Fauces, operations on the,   .     .  UL  49
Felt splints in fractures, .     .     .  Ui. 889
Female, imperforate anus  in,  .     .  iU. 759
       polypi of the urethra,  .     .  Ui. 741
       sexual organs, operatiops on,  UL 450
       stone in the bladder, and how
         removed by high operation
         of lithotomy,   .     .  UL 641, 916
           see Uterus and Vagina. 
INDEX,
969
                                      TA.QK
 Femoral aneurism, case of)   ,     .   L 958
       artery, compression of,      .   i. 687
       artery, ligature of,   i. 777, 901, 950
       Statistics of ligature of femoral
         artery.....L 782
       ligature of branches of the  ,   L 783
       or crural hernia, .    .     .iii. 354
       or complicated cases  of,     . Ui. 364
       Strangulated,     .    .     . iii. 358
       operation for,     .    ,     . ui. 359
 Femur, congenital dislocation of,   . iii. 855
       exostosis of)      .    .     .  U. 723
       exsection,     u. 296, 305, 434—139
       exsection of the head of the, Ui. 504
       fracture of the,   .    .     . iu. 893
       bandages for fractures of)   .   L 189
       necrosis of,  .     .    .     .  U. 545
       section of the, for  ankylosis of
         the knee,      .    .     .   i. 487
       trephining the,  .    i. 172, iL 545
 Fibrous growths in general,   .     .  ii. 700
       tumors,     .      .    .   U 691, 700
       discussion upon, and cancer-
         ous tumors, in the French
         Academy,
       tumors of the breast,
       tumors of the cranium,
       tumors of the vulva,
            sec Tumors.
 Fibula, bandages for fracture of)
       exsection of)      ,
       exostosis of,
       trephining of,
 Fibular  artery,  ligature
         wounds of,
       nerve, excision of)
 Figure of 8 bandage,    ,
 Filing the  teeth,  ,
 FilUng or plugging the teeth, .     .   i. 319
 Fingers, completely  separated,  restored,
                                     i. 556
       and toes, anaplasty of,
       adhesion,  retraction  and de
         viation,  .     .    .     ,
       amputation of,       r     ,
       anchylosis of,    .    .     ,
       division of tendons of the,   .
       of ligaments of the,   ,
Fire-arms,  wounds by,  .
Fissures of the anus,
       maxillary,  ....
       of the perinaeum, .
Fish-hook in the oesophagus,  how ex-
         tracted,  .     .    .    . Ui. 168
Fistulas, abdominal,     .    ,    .iii. 195
       after amputation,     .     . iL   3
       in ano,     .     .     .  UL  788, 933
         operation  for,  not  to  be
         performed in cases of pthisis,
                                  iiL 803
       eptero-vaginal,  .     .     . UL 537
       of the kidney,    .     .     . UL 751
       lachrymal,  .     .     .     . U. 786
       umbilical,   .     .     .     . iii. 751
           see Appendix i. lxiu.
       pharyngeal,      .     .     , iii. 156
       parotid,     .     .     .     . hi.  26
 VOL.  III.                               122
,	. ii.	705
	. n.	699
m,	. n.	755
	. m.	454
•e of)	. i.	188
u. 292,	431,	487
.	. u.	722
.	. u.	545
of) and		
,	. l.	756
•	. u. . i. . i.	55 177 319
   i. 556

,  L 385
,  U 136
.   L 488
.   i. 407
•   L474
u. 69, 73
.  Ui. 780
.  UL  13
.  UL 538
L	619
ui.	213
11L	33
UI.	751
UI.	751
IU.	750
111.	872
UL	873
i.	624
iu.	521
Fistulas—continued.
       recto-vaginal,    ,    iL 534, Ui. 867
       recto-vesical,     .     .     .  iii. 750
       saUvary,    .     .     .     .  Ui.  26
       stercoral, anaplasty of) artifi-
         cial anus, &c,  .
       of the stomach,  .
       of submaxUlary gland,.
       urethral,    .
       of ureter,
       urinary,
       vesico-uterine,
       vesico-utero-vaginal,  .
       vesico-vaginal,  anaplasty
         cases of,
       vesico-
       also for a new and  successful
         method of operating, see Ui. 874—
                                      887
Flax, tow, &c,  in dressings,  .     .  i. 106
Flap operations,   .     .     i. 105, ii. 236
Flexible  catheters,      .    .     . Ui. 710
Foetus extra uterine, extracted  from
                                  iii. 866
                                   iii. 433
                                   i. 398
                                   i. 115
                                   i. 220
                                  iii. 714
                                  iii. 718
                                   u. 162
                                   L 907
                                   i. 486
                                   ii. 215
                                   i. 187
         the abdominal cavity,
       found in a scrotal tumor,
Foetuses, congenital adhesion of)   .
Folded compresses,
Fomentations,     ....
Forced catheterism,
       injections,   ....
Fore-arm, amputation of)     ,
Foot, arteries of the,
       anchylosis of the,
       amputation of the,
       bandages for fractures of the,
       excision of bones of) iL 292, 423, 478
       callosities on the,    .     .  i. 362
      corns on the,     .    .     .  i. 361
      division of the tendons of the,  L 416
      exostoses of the,  .    .     .  ii. 721
      Ugatures of arteries of the,  i. 756—
       neuromas of the, .
       tenotomy of the, .
       venesection in the,
       wounds of the,   .
       board,
Forceps, artery,
       ball,   .
       cutting,
       dissecting,  .    ,
       lithotomy,  .
       tooth, .
Forced catheterism,
       injections,  .
Fore-arm, arteries of,
       bandages for fractures
       amputations of,  .
       exostoses of)
       exsection of bones  of,

       nerves of)
       neuromas of)
       subcutaneous bridles of,
       trephining of bones  of).
Forehead, anaplasty of)  .
          763
     . U. 613
     .  i. 443
     .  i. 258
   L 756—763
     .  i. 133
     i. 43, 91
     .  U 749
     .  ii. 281
     .   i.  91
     .   i.  90
     .   i 600
     .   i 324
 Ui. 714—718
     .  Ui. 718
    L 811, 900
of)   .   i. 183
     .  u. 162
     .  ii. 719
  iL 286, 307,
          403
     .  iL  48
     .  ii. 613
     .  i. 391
     .  ii. 546
     .  i. 633 
970
INDEX.
                                     PAQ«
 Foreign bodies,   .    .    .    . ii. 734
       in the abdomen, .    .    . ii. 739
       in the anus,     .    .    . Ui. 768
       in the air passages,   .    . Ui. 841
       in the articulations,   .    . ii. 750
       baUs as,   .    .    .    . U 747
       in the bladder, UL  660, 603, 755, 840
           see CalculL
       in the bladder and urethra, . Ui. 755
       how extracted from the blad-
         der,     .    .    .    . Ui. 840
       in the brain,     .    .    .  ii. 531
       in the chest,     .    .     .  U. 735
       remarkable cases of)   .    .  U. 735
       in the cranium,     U. 631, 735, 774
       in the ear, .    .    .     .  UL 102
       extraction  of foreign  bodies
         from,     .     .     .     . iL 734
       in the  globe of the eye,   ii. 857,
                                   iii. 169
       in the hands and feet, .     .  iii. 168
       in the head,     .  U. 531, 735, 774
       in the integuments,   .     .  iiL 168
       in the larynx and trachea,  .  iU. 138
       laryngotomy  and tracheotomy
         for,       ....  iii. 150
       in the limbs,     .     .    .  U. 743
       in the nasal fossae,     .     .  U.  72
       needles and pins as,  ii. 742, iii. 168
       in the maxillary  sinus,      .  Ui.  96
       in the cesophagus,     . UL 162, 168
       tracheotomy,  for  removal of)  iii. 139
       in the pharynx,  .     .     .  iii. 156
       in the rectum,   .     .     .  iu. 768
       in the stomach and abdomen,
         and how extracted there-
         from,     .     .     u.  736, iii. 866
       in the thorax,    .     .     .  iL 735
       tracheotomy for the removal of)
                              Ui. 138, 150
       in the urinary passages,
       in the uterus,
       in the vagina,
Fossae nasal, operations  on,
         calcuU in,
         foreign bodies  in,
         hemorrhage from,   .
         polypi of) .
         polypi of frontal sinus,
Fractures of anchylosis,  .
       amputation in certain cases of, ii.  69
       bandages for,    .     .  L 182—187
       of clavicle,  ....  iii. 889
       of cranium, .     .     .     .  ii. 510
       statistics of fracture of cranium,
                                 ,  iL 512
       caustics  and  rasping  in  un-
         united,   .    .          .  iL 303
       cure of)  often  imperfect,     .  iU 900
       dressings, provisional,  for,  .  i. 191
       effect of friction on,   .     .  iL 300
       exsection  in  certain cases of
         compound,     .     .   iL 283, 304
       felt splints, their  use in,     .  in. 889
       of the femur,     .     .     .iiL 893
       of the frontal  bone,    .     .  ii. 629
       of the hand,.     .     .     .  L 183
11.	741
IU.	478
111.	746
UL	72
UI.	88
UL	72
111.	74
UL	75
UI.	90
*	484
 Fractures—continued.
       of the humerus,  .    .    . UL 889
         with exsection,     .    .  iL 290
         of its condyles,     .    . iii. 891
       of the head,     .    .    .  U. 524
       abscess of the Uver from,    .  ii. 532
       of the head, statistical table of)
                              U. 534—537
       of the leg,   .    .    .     .iii. 898
       use of adhesive strips  in the
         treatment of this,   .    . iii. 898
       of patella,   .    .    .    . ui. 896
       of penis, or laceration of the
         corpora cavernosa,  .    . iU. 924
       pocket handkerchiefs used as
         bandages in,  .    .  L 191—197
       of radius,    .... iii. 892
       statistical table of)    .    . Ui. 900
       starch   bandage,  and   wire
         gauze splint,  in the treat-
         ment of,  .    .    .    . iiL 888
       utero-gestation, its effects on,  U. 299
       badly united, how  straight-
         ened,     .    .    .    .  U 311
       un-united, acupuncture in,  .  U. 304
         effects of caustics and rasp-
           ing in,  .    .    .    .  iL 302
         of compression  and immo-
           bility in,    .    .    .  U. 300
         of friction in,  .    .    .     ib.
         of pregnancy in,    .     .  iL 299
         of perforations and the use
           of pegs, &c, .    .    .  iL 309
         of setons,.    .         .  iL 302
         wire gauze, how used in, . Ui. 888
         a new mode of treatment
           in,      .    .     .     . UL 907
Fraenum, division of,                iii. 896
       of prepuce, division of)     . iU. 444
Friction,.....i 271
Frictions, effect of) in un-united frac-
         tures,     .    .    .    .  ii. 300
Frontal bone, fracture of,     .    .  iL 529
       nerve, injury of,  .     .    .  iL  40
       sinus, abscesses of,    .     .   iL 773
       caries and necrosis of, .     .  U. 772
       sinus, diseases of)     .     .  U. 771
         foreign bodies  hi,   .     .   ii. 775
         fracture of,    .     .    .   ii. 771
         polypi of,      ...  Ui.  90
Frozen  limbs,  amputation in  cases
„   .    of......ii.  67
Fumigation,.....i. 221
Fungous tumors,   .    .     .   iL 553, 755
       case of  Ugature  of the caro-
         tid,  for the safe  removal
         of>.....i. 931
ii. 756
ii. 553
U. 654
iL 712
Fungus of the dura mater,
Funguses, or naevi materni,
Fungus hoematodes,
         of the bladder, .

                    G
Galvano-puncture in aneurisms,   .   i. 711
Ganglions,  lymphatic,   .     .     .  iL 585
       synovial,    .     .     .     .  jj  660
Ganghonic  transformations of nerves, iL  66 
INDEX.
971
Ganglionic tumors,     .     .     .  ii. 584
Gangrene, after amputation,  .     .  ii. 127
       amputation in certain cases of, iL  61
       spreading, amputation in cases
         of—Appendix i. IviL
       in aneurisms,    .    .     .  i. 667
       after Ugature of an artery, i. 746, 774
       in cases of strangulated hernia,
                              iii. 283, 610
       from exposure to severe cold—
         Appendix i.*xlv.
       of the scrotum, from injections
         in hydrocele,  .    .     .  UL 394
       hospital,    .    .    .    .  iL  61
Gargles,.....L 221
Gas effused into the thorax,  .     .  Ui. 180
Gastric juice as a  solvent of urinary
         calculi,    .    .    .    .  Ui. 702
Gastrotomy, for the removal of foreign
         bodies,    .    .    .    . ii. 741
       in cases of invagination of the
         intestines,    .    .    .  iu. 281
       in obstinate constipation,   .  iii. 319
       in cases of carcinoma, .    .  iii. 921
       remarkable case of,   .    .  iii. 864
Gauntlet, a bandage for the hand, .   i. 180
Gauze splints,  in fractures,   .    .  iii. 889
Generation, male organs of,  .    .  Ui. 375
       female organs of,     .    .  iii. 450
       baudages for the genital or-
         gans,      .     .    .    .  i. 171
       elephantiasis of male genital
         organs,   .     .    .    . Ui. 417
         of female genital organs,   iii. 454
Genocheiloplasty,  or  restoration of
         cheeks and Ups, .    . L 628, 639
Genoplasty,  or  restitution of the
         cheeks—see Anaplasty, .   L 601
Genital organs, male,    .    .    . iii. 375
         female.....Ui. 450
            see Generation.
         and abdomen, cicatrices, Ac.,
            of,      .     .    .    .   i. 395
Glass, fragments  of glass acting as
         foreign bodies, .    .    . iL 743
Glasses, cupping,   .     .    .    .  i. 273
Gland,  lachrymal, extirpation of,  .  ii. 815
       mammary, removal of)   UL 176, 478
       parotid,     .    .    .    . Ui. 115
       extirpation of)   .    . Ui. 119—127
       fistulas of)   ...      UL  26
       prostate, calcuU in,   .    .  UL 694
Glands, salivary, tumors of,  .    .  iii. 117
       extirpation of,   .    .   UL 115, 127
       submaxiUary,   .    .    iii.  33, 127
         extirpation of, .    .    . iii. 128
         fistulas of)                iiL  26
       thyroid,     .     .    -iii. 128, 943
Glandular, lymphatic tumors,.    .  ii. 584
Globe of the eye, diseases and opera-
         tions  on,  .    .    .    . U 837
           see Eye.
Glottis, oedematous condition  of—
         see Air passages,   .     .  iii. 137
Glutaeal and Ischiatic arteries, opera-
         tions  upon,    .   L 794, 905, 961
Glutinous,  or starch and dextrine
         bandages,      .     .     .  L 122
Goitre,.....iiL 128, 943
      tracheotomy in  certain cases
         of).....iii. 155
Graduated  compresses,  .     .     .  L 116
Groin, enlarged glands of the,     .  iL 589
      ulcers and abscesses of the, .  iL 592
Gouges, mallet, and various kinds of
         saws, &c,     .     .     .  iL 282
           see Exsections.
Gums, incisions of,      .     .     .  L 313
Gum-elastic bougies,    .     .     . Ui. 725
Gun-cotton in aether, or coUodion,  as
         a dressing,    .     .     . iii. 852
Gun-shot wounds,  .    .    .     iL 69,  73
       amputation in cases of,     .  ii.   69
       of axUla,  with Ugature of the
       subclavian artery,     .     .  i. 962
       of the brain,     .     .     .  U. 531
       exsection of bones, in  cases
         of).....U. 284
Gustatory  nerve, operations on,    .  iL   46
Ham-strings, accidental division of)   L 422
Hand, anchylosis of)     .     .    .  L 489
      arteries of)       .     .   i. 808, 900
      bandages for,     .     .   i. 180, 183
      bandages for fractures of the,  i. 183
      bleeding from the,     .    .  i. 254
      division of tendons of the,  .  L 412
      exsection  of  the bones of the,
                               u. 286, 402
      exsection  of the  articulation
         of the.....U 449
       exostoses of the,      .    .  iL 719
      neuromas of the, .     .    .  iL 613
      tenotomy of the, .     .     .  i. 438
Handkerchiefs as bandages,  .    .  i. 191
Hair-pins,  in the bladder, how ex-
         tracted,  .     .     .    . UL 840
      used to extract foreign bodies
         from the nose, .     .    . iii.   72
Hairy ball, in the rectum,    .    .  ii. 769
Hare-lip,     .     .     .         UL 1, 902
      simple,     .     .     .    . iiL    1
      complicated,     .     .    . iiL    2
      anaplasty in cases of,  .    .  i. 640
      early operations of)    .    . Ui. 902
      operation for,     .     .    . iiL 334
Head, arteries of the,    .     .    .  i. 844
      Ugature  of these arteries in
         cases of erectile tumors, .  ii. 572
      bandages for the,.     .    .  i. 191
      foreign bodies in the, iL 531, 735,
                                     744
      fungous tumors of the,.    .  ii. 755
      injuries of the,  concussion, 4c, ii. 523
      operations on the,     .    .   ii. 755
      redressers (bandages) of the,  i. 154
      tenotomy of tendons and mus-
         cles of the,     .     .    .  i. 464
      trephining of the,      .    .  U 509
      wounds of the,   .     .    .  ii. 523
      statistical table of wounds of)  iL 532 
972
INDEX.
Heart, cases of rupture of the,  L 750—754
       wounds of the,   .    .   L 671, 754
Hematic cysts,    .     .    .     .  ii. 647
       tumors,    .     .    .     .  iL 633
       tumors of female genital or-
         gans,    ....  iii. 451
Hematocele,.....UL 412
       excision of the tunica vaginalis,
         in cases of,                Ui. 415
       injection, in cases of)  .     .  UL 416
       incision, hi cases of)   .     .  U 417
Hoematodes fungus,     .    .     .  u. 554
Hemorrhage, alveolar,  .    .     .   i. 693
       from castration,  .     .     .  iii. 431
       during amputation,    .     .  ii. 118
       after amputation,      .     .  iL 119
       how prevented,  .     .     .  iL   3
       during operations,    .     .   L  25
       after operations,      .     L 42, 65
       from the ear,     .    .     .  ii. 626
       after operation for  fistula  in
         ano,      ....  iii. 801
       from hemorrhoids,     .     .  UL 773
       from leeches,     .    .     ,   i. 267
       after ligature of arteries,   .   i. 747
       from the nose,   .     .     .  iU.  74
       after lithotomy,  .    .  Ui. 605, 698
       after the high operation,    .  iiL 637
       after operation for hydrocele,  iii. 396
       after removal of tonsils,     .  iii. 946
       traumatic,  .     .    .     .   i. 671
       treatment, medical,    .     .   L 674
         by compression of arteries,   i. 690
         by refrigerants and styptics, L 676
         by surgical treatment,    .   L 679
         by sponge,  its use in,     .   i. 701
Hemorrhagic diathesis,  .    .     .   L 747
Hemorrhoids  and hemorrhoidal  tu-
         mors,    .     .    .     .iii. 771
Hemostatic means in amputation,  .  ii.   3
Hernia,.....,  iu. 215
       artificial anus from,    .     ,  iiL 297
       bandages, or trusses for,     .  L 200
       canals, hernial,        ,     .  iii. 219
       cough,  impulse in,    .     .  iii. 905
       coverings of)     .    .     .  iU. 215
       crural,      .     .    .     .  ui. 354
       diaphragmatic,   .    .     ,  iii. 273
       enterotomy,      .    .     . Ui. 304
       epiplocele,  .     .    .     .  UL 270
       femoral, or crural,    ,     .  UL 354
       gangrene with,  .    .     .  iii. 285
       incarcerated,     .    .     .  iii. 223
       indications of strangulation in, UL 239
       inguinal,   ....  iiL 323
       varieties of)      .    .  UL 323, 330
       irreducible, .    .    .     .iii. 323
       internal,   .    .    .  iiL 279, 373
       intestine perforation of)     . UL 286
       intestine, wounds  of) in  the
         operation for,   .    .    .iii 295
       ischiatic,   .     .    .    . Ui 373
       see Appendix L lxii.
       intersusception,  or  internal
         strangulation,  .    .    .iiL 279
       obstructed, .     .    .    , iii. 233
       obturator, or thyroid, .    . iii 372
Hernia—continued.
      omental.....iii- 270
      openings, hernial,     .    . iii. 218
      operation for strangulated,  . iii. 253
      perforation of intestine in,  . iii. 286
      perinaeai   .... iii. 373
      radical cure of,   .    . iii. 220, 906
      reduction  of, various  means
         of).....UL 240
      reduction of, in mass,  .     . iii. 903
      rings, hernial,    .    .    . iii 218
      sac, hernial,   • .    .    . iu. 215
      strangulated,    .    .    .iii 233
         internally,     .    .    . Ui. 279
         operation for,  .    .    . iii. 253
         without opening the sac,  iii. 253,
                                      905
      taxis, .     .     .     .  ui. 239, 904
      table, statistical, of,   .    . iU. 374
      table, statistical, of reduction
         by taxis, .... iii. 903
      umbihcal,   .... iii. 365
      vaginal,    .     .    .     .iiL 373
      various means of,      UL 240—251
      varieties of)     ... Ui. 323
      ventral,    .... iii. 371
      viscera involved in,   .    . iii. 215
      vulvar,     .    .    .     . UL 373
           see also Inguinal and  Crural.
      cerebri,    .    .    .     .  U. 713
Herniotomy, or  the  operation   for
         strangulated  hernia,      . iii. 253
Hernial sac, nature of,  .    .    . iii. 216
      hydrocele of a hernial sac,   . iii. 405
Hearing, organs of—see Ear,       . iii. 100
Highmore, antrum of—-see MaxiUary
         sinus,    .    .    .    . iii.  93
High operation of Uthotomy, .    . Ui. 620
Hip-joint, anchylosis of, .    .     . iii. 819
      amputation at,    .     .  U. 255, 267
      statistical  tables of)   .    .  iL 257
Hoops,......L 136
Hot air in dressing,      .     .     .  i. 219
Horny plates on the eye;     .     .  ii. 840
       tumors,    .    .    .     .  ii. 551
Horses, tracheotomy in,      ,     .iiL 142
Hospital gangrene,      .     .     .  iL  62
       after amputation,     .     .  iL 127
Humerus, bandages for fractures of
         the,                     .  L 184
       enchondoma of the,    .     .  ii. 673
       exostosis of)          .  U. 308, 720
       exsection  of the,    ii. 288, 407, 465
       exsection  of false joint of the,  ii. 308
                                   iii. 890
                                   iiL 891
                                    ii. 673
                                    ii. 547
                                    L 820
                                   iiL 402
                                  . iii. 207
                         iiL 375—413, 907
                                  . iii. 397
                                  . iii. 908
                                  . iiL 400
                                  . iii. 403
                                  . UL 406
       fracture of the,
       fracture of the condyles,
       spUnt for fractured,
       trephining of the,
Humeral artery, ligature of,  .
Hydatids in hydrocele,
       of the liver,
Hydrocele,
       acupuncture in,
       cauterization in,
       complicated,
       congenital,
       of the cord, 
INDEX.
973
Hydrocele—continued.	
diagnosis of, .	. iii. 380
encysted,	. Ui. 408
excision of)	. Ui. 388
of hernial sac,	. iii. 405
with hernia,	. Ui. 402
      iodine injections in, ui. 398, 411, 907
      incision in.....iii. 387
      inguinal hernia with,   .     . iii. 338
      injections in,     . Ui. 389, 398, 907
      nitrate of silver, its use in, Ui. 385, 908
      operation for cure of,   .     . iii. 391
         accidents from the,  .     . Ui. 394
         dressing after, .     .     . iii. 393
      Betons in,   .     .     .     . iii. 386
      spermatozoa in,  .     .     . iiL 413
      tents in,              .     . iii. 385
      testicle, its condition in,    . iii. 379
      treatment of,     .     .     . iii. 383
      in women,  .... iii. 409
Hydrocephalus,    .     .     iL 765, iii. 908
      see Appendix i. lxU.
Hydropic tumors, between the layers
         of peritonaeum,     .     .  ii. 673
Hydrophobia,  amputation in cases Of, U.  82
Hydrophthalmia,  .     .     .     . ii. 899
Hygroma,    .    .     .    .     . Ui. 674
Hypochondria, fatty tumors of,     .  ii. 625
Hypogastric operation of lithotomy, iii. 620
      puncture of the bladder,    . iii. 746
                                 . iii.  18
                                 . u. 606
                                 . iii. 932
                                Ui. 48, 944
                                 . Ui.  49
                                 . iii. 754
                                 . iL 900
                             in re-
                                 . UL 251
                                  . Ui. 458
                                        9
Immovable apparatus for fraotures,   L 124
      dressings in fractures,  .    .  ii. 301
Imperforate anus,  .     .    .iiL 758, 837
      rectum,     .     .    .    . Ui. 757
      artificial anus in cases of)  . Ui. 316
      vagina,     .     .    .    . Ui. 950
      vulva,      .     .     iii. 458—162
Incarcerated hernia,     .    .    . Ui. 233
Incisions in fissures of the anus,  . iii. 785
      in fistula in ano, .
      in hydrocele,
      in haematocele,   .
      manner of making,
      for radical cure of hernia,
      of sphincter am, .
      in strictures of the urethra,
      of varices,  .
Index,  general, at  the end of 3d
         volume.
Indian method  of anaplasty,  .
Indications in operating,
Infancy, operation for hare-lip in,
Infants, imperforate anus in,  .
Infection, purulent,  .    .    i. 75, U. 129
Inferior maxiUary bone, immobility
         of,    .    i. 478, Ui. 21, 811, 819
       excision of)     ...     329
       statistical tables of excision of
Hypertrophy of the hps,
       of lymphatic glands,
       of septum nasi,
       of the tongue,
       of the tonsils,
Hypospadias, .
Hypopion,
Hyoscyamus and  beUadonna,
         duction of hernia,
Hymen,
Hygienic precautions in operations,    i
Hysterotomy,  abdominal,  or  the_
         Caesarean section,  .    . iii. 911
       vaginal,    .    .     .    • nL 912

                     I
Iced applications in hernia,  .    . iii 250
Heum, perforation of the,     .    . Ui. 322
Iliac arteries, compression of) .    .  i 688
       artery,  external    operations
         upon,     .   i.  786, 905, 941, 953
       artery, internai .    L 792, 904, 961
       statistics of Ugature of the in-
         ternal,   .     .     .     .  i 794
       primitive, first case of Ugature
         of, for aneurism,    .    .  i 941
       primitive, ligature  of,  .  i 801, 904
       statistical table of Ugature of,  i 803
Imbedded toe-naU,      .     .   i 363, 374
Immediate amputations, .    .    • "•  90
       union by first intention in, .  i.  55
       apparatus, for fractures,     .  i 124
ImmobUity of  the  eye,  after  the
         operation of strabismus,  .  l 528
       of the lower  jaw,    i 478, iii. 21,
                                 811, 819
Immobility of the pupil, in cataract,  ii. 844
Ui. 796
iiL 387
Ui. 417
 L 330
Ui. 223
iii. 785
iii. 719
 iL   5
 i. 565
 L   7
u. 341
Ui. 769
this bone,	. ii. 339
operations on this bone,	. iL 45
Inflammation, after operations,	. L 67
in aneurismal sacs,	. L 667
compression of arteries in,	. L 619
from venesection,	. L 260
Infra orbitar nerve, operations	on
the, . . • .	. U. 41
Inguinal glands, enlargement of,	. ii. 589
Inguinal hernia,	. iiL 323
bandages for, . .	. Ui. 339
compUcations of) .	. iU. 336
diagnosis of)	. UL 335
envelops, or coverings of)	. Ui. 331
in the female,	. Ui. 330
infantile,	. iii. 330
operation for,	. Ui. 336
	
new species of) .	. Ui. 354
with rupture of the sac,	. Ui. 346
reducible large, successfully,	
operated on,	. iii. 354
radical cure of, . . UL 231, 353	
rupture of the sac,	. iu. 319
spermatic cord in,	. iii. 333
strangulated,	. iU 341
operation for, .	. Ui. 346
of tunica vaginalis,	. iii. 327
sac of this,	. UL 331
various forms of, . . UL	323—330
viscera involved in,	. Ui. 330
see Hernia.	
Inguinal lymphatic tumors, .	. u. 690
Injections, ....	. L 222
in ascites, after tapping,	. iU 201
in erectile tumors,	. ii. 586
forced,	. iU. 718
foreign bodies in the ear,	re-
moved by,	. UL 105
 
974                                   INDEX.
. UL	417
. u.	67
. ui.	604
. UL	628
. HI.	664
. UL	35
I nasal	
. IL	791
. in.	26
. u.	688
. in.	762
. u.	523
. IL	76
 Injections—continued.
       in goitre,    .     .     .     . UL 131
       in hematic synovial cysts,   .  iL 658
       in hydrocele,      iii. 389, 398—411
       in hematocele,
       in hydropic tumors,
       after lithotomy,  .
       before lithotomy,
       in lithotrity,
       in ranula,   .
       in sac lachrymal,  and
         duct,
       in salivary fistulas,
       in synovial cysts,
       in urethral fistulas,
Injuries of the head,
       railroad,
Innonunata artery, the first case of
         ligature of this artery,     . i. 912
       aneurisms of,       i. 874—883, 945
       diagnosis of, .     .    .     . i. 878
       artery, operations upon,  i. 894, 914,
                                       975
       aneurisms of this artery, treated
         by ligature of either the caro-
         tid, or subclavian, or both,  L 876
       Ugature of the,    .     .  i. 877, 912
       statistics  of ligature of this ar-
         tery,     .    .    .     .  L 881
Insects in the ear, .    .    .     . iU. 103
Instruments  and dressings in surgical
         operations,    .    .     .  L 17
       for  dressing,   in   the   minor
         operations,    .    .     .  i. 90
       cutting,     .     .    .     .  i. 328
Integuments, tumors of) .    .    . ii. 549
Intention, union by first and second, L 54—61
Intercostal arteries, wounds of) i. 889, iii. 190
       nerves, neuromas of)  .     . ii. 618
Internal  ear, diseases of,     .    . Ui. 108
       inguinal hernia, .    .     . iii. 326
       iUac artery, ligature of)   L 792, 904
       jugular vein, its rupture,     . U. 34
       mammary artery,     .     .  i. 889
       strangulation of intestines,    iii. 279
       urinary fistulas, .
Intestines, artificial anus of,  .
       large, operations on,  .
       small, obliteration of, and ar-
         tificial anus, to relieve it,  iii. 318
       Btricture  of)  in  hernia—see
         Hernia,  .    .    .     . Ui. 235
       wounds of,  in hernia,  .     . UL 295
Intra-cranial aneurisms, .    .     .  L 845
Intussusceptio, or strangulation of the
         intestines,      . Ui. 279, 645, 650
       gastrotomy in cases of,      . iii. 319
Invaginated  integuments  for   the
         radical cure of hernia,    . UL 225
       intestine, in cases of artificial
         anus,     .    .    . #    . iiL 298
Inversion of the eyelashes, or trichea-
         sis, .     .     .     .     . ii 821
Inverted toe-nail,   .     .    ;  i 363, 374
Inversion of the uterus, .     .     . UL 510
Iodine injections, in cysts and  cavi-
         ties,      .     .     •     • ui 90
iii. 751
Ui 318
UL 758
i
Iodine—continued.
       in cysts of the thyroid gland, iii. 943
       in enlarged bursie,      ii. 681—688
       hi encysted hydropic tumors
         of peritonaeum,     .     .  ii. 673
       in hydrocele,     .    . hi. 398, 411
       in ranula,  .... iii. 929
       in opina bifida,   .    .     . iii. 937
Iridoplasty,.....Ui. 913
Iris, contraction of) in cases  of cata-
         ract,     .... iii. 852
       prolapsus of,      .    .     •  ii. 853
       tremulous, .     .    .     .  U. 845
Iron, lactate  of) as an injection,  in
         erectUe tumors, aneurisms,
         &c,       .     .    i  678, U. 568
       perchloride  of)   its  use,  in
         aneurisms    and   hemor-
         rhages.....i. 677
Irrigations, in dressing,  .    .     .   i. 216
Irreducible  inguinal hernia/—see In-
         guinal Hernia,     .     . iU. 339
Irritating  injections,   in   synovial
         cysts,    .     .    .     .  U. 688
Ischiatic artery, ligature of)  .     .   L 794
       hernia,     .... iii. 373
Ischium, partial exsection of, .     .  ii. 398
Isinglass plaster,  .     .    .     .   i. 128
Issues,......L 285
       see also Setons and Caustics.
ItaUan method of anaplasty, .     .   L 563
Jaw, lower, bandages for,     .     .   i. 192
       exsection, partial, of the lower, iL 329
       cases of exsection,     . ii. 347—374
           Appendix i. 1., L lviii.
       statistical table of exsections
         of the  lower,  .     .     .  iL 339
       immobiUty of the lower,    .  i. 478,
                           UL 21, 811, 819
       removal of dental border of the
         lower,    .    .     .     .  iL 343
       rigidity of the ligaments of the
         lower,  and their division,    L 477
       upper,   exsection of)  iL  375,
         Appendix i" L
       fissures of, .    .     .     . iu.  13
Joints, loose cartilages in,     .     .  iL 762
       artificial,   .    .     .     .   i. 489
       exsection of false and artifi-
         cial,      .    .     . ii. 302—305
       exsection of,     .     .  U. 282, 440
           see  Exsections and Ar-
              ticulations.
       exsection of parts, of the ex-
         tremities,     .     .     .   L 490
       exsection of the elbow,     .  iL 461
       exsection of foreign bodies in
         the,      .    .     .     .  iL 751
       exsection of bones of hand, .  u. 443
       hip, amputation at the,     .  iL 255
       hip, ankylosis of the,   .     . iii. 819
       making of new,  .     .     .   i. 489
       knee, amputation at the,    .  ii. 236
       knee, ankylosis of,     .     . UL 821
       knee, exsection of)          .  U. 490 
INDEX.
975
  .                                  PAGE
Jomts—continued.
       knee, foreign bodies in, loose
         cartilages, &c,      .    .  ii. 751
       metacarpal, exsection of)   .  U. 444
       thumb, first phalanx  of the,
         its exsection,   .     .    .  ii. 443
       exsection of the wrist,  .    .  U. 447
Jugular vein, bleeding in,     .    .   i. 254
       ligature of  .     .     .    .   L  37
       rupture of into an abscess, ii.  34—36
       wounds of)  .     .     .    .  iL   1
Keratotomy, or  the  extraction  of
         cataract, through the cor-
         nea,     .    .    .    . U 888
Keratonyxis,  in  cataract,  or  the
         operation, through the cor-
         nea, .    .    .    . ii. 850, 882
Keratoplasty, or  the  transplantation
         of the cornea, .    .     .  i. 591
Kidney, calculi in, .    .    .     . UL 691
       fistulas of,  .    .     .    . iii. 751
Kirsocele, or Circosele, .     .    . ii.  21
Kneading,.....i. 277
Knee-joint,  amputation at,   i. 950, u. 236,
                                      243
       ankylosis of,      i. 486, iu. 819, 821
       exsection  of,      .     L 492, ii. 490
       hematic cysts of,     .     . iL 656
       hematic tumors of)    .     . iL 637
       neuromas of)                . iL 613
       perforation of the  bone  in
         cases of anchylosis of the,  Ui. 820
       statistical table of amputations
         at the,    .     .     .     . iL 241
Knee-pan, or patella, exsection of)  u. 602
       rupture,  or  division of the
         tendon of,     .     .     .  L 422
       tenotomy of)                .  i. 462
       section of Ugament of, in cases
         of rigidity,    .    .     .  i. 477
Knot tighteners,    .    .    .     . U. 732
Knives extracted from the stomach, Ui. 866
Labia majora, abscesses  and tumors
         of,.....iu. 450
       minora,    .     .    .    . Ui. 453
Labor, operations, required in  diffi-
         cult,     .     .    .     .iii. 545
       Caesarean section,    .    .iiL 548
       symphysiotomy,  .    .    . iii. 545
       vaginal uterotomy,    .     . iii. 554
       rupture of uterus in difficult,  iiL 555
Laceration  of  corpus  cavernosum
         penis,    .     .    .    • ui. 924
Lachrymal cysts,  .
       fistulas,
       gland,  extirpation of)
       passages,   .
       sac, restitution of)
       tumors,
Lactate of iron, as  an  injection in
         aneurisms, erectile  tumors,
         Ac,      .      .    .   678, u. 568
Lallemand's caustic to the urethra,  UL 733
   .  U. 786
iL 787—806
   .  ii. 815
   .  iL 783
   .  i. 592
   .  U. 787
Lancets,      .          .     .     .   L 238
Lapis infernalis,  or  the  nitrate  of
         silver.....i. 294
Larynx and trachea, anaplasty of, .   i. 610
      catheterism of the,     .     .  iii. 156
      exsection  of portions of the,
         and trachea,   .     .    .  ii. 389
      morbid growths in the,     .  iu. 914
Laryngitis, chronic, tracheotomy in,  iii. 142
      cedematous,      .     .     .  iii. 137
iiL 143—156
    . UL 149

    . Ui. 150
267
Laryngotomy,
      cricoidean,  .
      thyroidean, .
      thyro-hyoidean,
Laryngeal phthisis,  tracheotomy,  in
         cases of)  .    .     .     .iiL 141
Lateral  operation of lithotomy,     . UL 575
Lead bar, removed from the stomach,
                                  iii. 864
Leech bites, effects of)   .     .     .   i. 270
Leeches,.....L 265
      in erysipelas,    .     .     .   i.  73
      hemorrhage from leeches, how
         arrested, ....
Legs, artificial,    .    .     .     .  iL 276
Left subclavian  artery, first  case  of
         ligature  of)  between the
         scaleni muscles,     .     .   i. 835
           see Arteries.
Leg, amputation of the, .    .  U 222, 543
      artificial legs,    .     .     .  iL 276
      bandages for fracture  of the,   L 187
      deformed, from  fracture, suc-
         cessfully treated,    .     .  ii. 312
       compression of arteries of the,  L 686
       exostosis of the, .     .     .  iL 722
       exsection of the bones of the, U. 292,
                                      416
       exsection of false joint of the, ii. 308
       fatty tumors of the,   .     .  U. 628
       flex, or tendons of the, tenot-
         omy of,  .    .     .     .   i. 457
      fractures of the, .     .     .iiL 898
      adhesive strips  in the  treat-
         ment of fractures,
      subcutaneous bridles and cica-
         trices of the,
      tendons of the,  partiaUy ex-
         cised, in casos of paralysis,
      trephining the bones of  the,
Lens, opacity of, or cataract,  .
      ossification of)
           see Cataract
Lesions of arteries—see Arteries,
Levator palpetrae,  myotomy of,
Ligaments, division of)  .
      deformities from rigidity of)
Ligating arteries, method of,
Ligatures, in operations,
of arteries—see Arteries,   .  i. 662
in aneurisms,  ,      .    .  i. 712
of both ends  of an artery, in
  wounds.....i. 733
of arteries, in castration,    . Ui. 429
double,  with  section of the
  artery between,    .    .  i. 723
    ib.

 i. 394

 i.457
U 542
u. 841
ii. 854
L665
L757
L474
i. 474
L907
i. 26, 43, 53 
976                                  INDEX.
Ligatures—continued.
       of arteries, in cases of erectile
         tumors,  .    .    .    .  U 560
       in fistula in ano, .    .    . Ui. 794
       in goitre,        .    .    . Ui. 130
       in hemorrhoids,  .    .    . iii. 771
       in mass,    .    .    .    .  U. 726
       for removal  of polypi of the
           nose,  .... iii.  82
         polypi of the ear,   .    . iii. 106
         polypi of tho uterus,     . UL 483
         thyroid gland, .    .    . iii. 130
       of the tongue,    .    .    . UL  45
       of the tonsils,    .    .    . UL  50
       of varices,  .    .    .  U. 4, 18—24
    .   of veins, in varicocele,  .    .   i. 21
       separation of, after operations,   i. 63
       of stumps,  .    .    .    .  ii. 117
       successful extirpation of  the
         uterus, by,               Ui. 557
       of tonsUs,  .    .    .    . hi.  50
       uterine polypi, removed by,  UL 483
Limbs, almost  divided, their  ampu-
         tation,   .    .     .     .  iL  60
       artificial,   .    .    .    .  ii. 276
       bandages for the,      .     .   i. 180
       exsection of)  L400—478, ii. 423—-509
       foreign bodies  in the,  .     .  U. 743
       how saved from amputation,  ii 271
       statistical table of the  mor-
         taUty of amputation of the,  ii 133
       straightening of angular and
         curved,  .     .    .     .  U. 311
       supernumerary, .     .     .  U.  82
       useless,     .    .    .     .  U.  85
       vessels of) how affected by the
         ligature,  .     .     .     .   i 662
Lime moxas,       .    .    .     .   i. 302
Linea alba, hernia of,  or ventral her-
         nia, .....Ui 371
Linen in dressings,      .    .     .   i 111
Lingual artery, ligature of,   .    .   i 849
Liniments,.....i. 219
Lint,......L 102
Liquid dressings,  ...     .   L 216
Lipoma, Upomatous, or fatty tumors,
         or wens,  .    .    .     .  u. 619
           see Appendix L liii
Lips, anaplasty of) .    .    .  L 582, 655
       cases of)    ....   i. 628
       see Cheiloplasty, .     .     .   L 592
       bandges for the, .     .     .   i 159
       cancer of the,   .     .     . Ui  15
       compression of the arteries of
deformities of the,	. Ui. 1
See Harelip,	. UL 1
eversion of) and projection of	
the mucous membrane of	
	. iii 17
hypertrophy of the,	. Ui 18
operations on the,	. iii. 1
tumors of the,	. iii 19
Liquid dressings, .	. ii. 215
Lithotomy,	Ui 568, 916
in women, .	Ui 641, 697
bilateral operation,	. Ui 687
Lithotomy—conti nued.
       dangers of,  .     •     •  ... •  ul- 687
       high operation,   .     .  iii- 620, 698
       in women,  .     .     •     •  1U- 916
       hypogastric, or  high opera-
         tion,     .     •     •     -iii 620
       statistics of the high operation, iii 916
         see Appendix i. lix.
       obUque or  lateraUzed opera-
         tion,     .     .     .     .  UL 576
       perinaeal, or infra pubic opera-
         tion,     .     .     .     -iji- 669
       accidents from,   .     .     .  iii. 605
       in pregnant females,   .     .  iii. 915
       quadrilateral operation,     .  iii. 592
       recto-vesicle operation,     .  Ui. 609
       statistical table  of recto-vesi-
         cal operations, .     .     .  iii. 615
       statistics of,           .  UL 677, 701
       statistics  of the influence of
         age on the  mortaUty from
         this operation, .     .     .  in. 916
       vesico-vaginal,   .     .     .  Ui. 643
       statistics of this operation,  .  Ui. 677
Lithotrity,    .     .     .  UL 651, 697, 918
       in children, .     .     .     .iii. 700
           Appendix L lvU.
       dangers of,  .     .     .     .  UL 687
       difficulties of the operation, .  Ui. 672
       instrument  used in,   .     .  iii. 655
       statistics of,      .     .  iu. 697, 701
       comparative examination of
         lithotomy and,      .     .  UL 675
       comparative mortality of  this
         operation,  in  Paris   and
         London,  .     .     .     .  UL 918
Liver,  abscesses  of  the,  following
         wounds of the head,.     .  U. 532
       encysted, dropsy of the,     .  iU. 207
       hydatids of the,  .     .  in. 207, 918
       humoral tumors of the,     .  UL 201
       paracentesis of the,    .     .  iii. 918
Lobe of the ear, perforation of,     .   i. 313
       tumors of)  .     .     .     .  UL 100
           see Ear.
Local bleeding,    .     .     .    .   L 264
Location, or place, where  operations
         should be performed, .     i   16
Longitudinal sinus, involved in a re-
         markable   operation*—Ap-
         pendix L L
Lotions,......L 220
Lower extremities, amputation of—
         see Amputations,   .     .  iL 193
       artificial  articulations,  how
         made,    .     .     .     .   L 490
       bandages for,     .     .     .   i. 196
       bandages for fracture of the,   i. 181
       exsection of)     .     .     .  u. 423
       trephining of)     .     .     .  U. 642
Lower jaw, bandages for the,      .   L 192
       exsection of the, .     ..   .  iL 829
       cases of exsection,     .  iL 347—374
           see also  Appendix L L,
             also i. IviiL
       statistical table  of  cases of
         exsection of the,     .     .  u. 339 
INDEX.
977
_.                                    FAUB
Lower jaw—continued.
      false anchylosis of the,   iii. 21, 819
      immobUity of the, L 478, UL 21, 811,
                                      819
      removal of the dental border
         of the,    .     .    .     .  ii. 343
      removal of the lower border
         of the,   .     .    .     .  iL 344
Luxations,.....iii. 853
      amputation in certain  cases
         of).....U.  69
       of the clavicle, bandages for,  i. 186,
                                  iiL 889
      chloroform and ether, in  re-
         duction of)     .    .     , UL 855
      of the hip,  new mode of reduc-
         ing,      .     .    .     . UL 850
      congenital dislocation of the
         femur,   .... iii. 855
      twisted rope in reduction of, Ui. 854
Lymphatic glands, extirpation of)   iii. 827
- hypertrophy of) .	. iL 606
system,	. i. 37
tumors,	. ii. 584
vessels dilated, .	. ii. 38
Lymphorrhagia,	. U. 37
M Male organs of generation,	opera-
tions upon,	. iu. 375
Malar bone, exsection of)	. ii. 327
MaUeolar hematic cysts,	. ii. 656
MaUeoU, exsection of the,	ii. 429—434
Mallet, gouges, saws, &c—be	e Ex-
sections, .	. ii. 282
MaUgnant disease of the anus,	iii. 805, 865
of the bladder,	. ii. 712
of the breast, . i	i. 698, iii. 170
of the cervix uteri,	. iii. 498, 538
of the colon,	. iu. 321
of the cranium, .	. ii. 757
of the eye, .	. ii. 905
of the eyeUds,	. ii. 829
of the lips, .	. iii. 15
of the nose,	. ii. 778
of the pelvis,	. U. 905
of the tonsils,	. iii. 57
of the uterine neck,	. iii. 498
of the uterus,	. iii. 588
statistics of)	. ii. 699
       discussion upon, in the French
         Academy,     .    .     .  ii. 705
       deductions from  the considera-
         tions of many cases of,   .  iii. 847
         see also Cancer and Carcinoma.
       tumors,     .     .    .     .  U. 694
Maltese cross,     .    .    .     .   i. 114
Mammae, bandages for,  .    .     .   i. 166
       cancer of,   .    .    .     .  ii. 698
       extirpation of,   .    .     .  UL 176
           see Breast.
Mammary artery, internal, Ugature of, L 889
       gland, cancer of, .    .     .  U. 698
         removal of)
         tumors,   .
         fibrous tumors of]
Mask, a face bandage,  .
   VOL. III.
iii. 176
iii. 170
 ii. 698
 i. 160
     123
		PAG«
	. UI.	712
L	5. iii.	820
	. iu.	110
3	of	
	. i.	677
Master turn of the catheter,
           see Catheterism.
Masseter muscle, division of,
Mastoid ceUs, perforation of,
Matico  as  a  styptic, in  cast
         hemorrhage,
MaxUla, inferior, or  lower jaw,  an-
         chylosis of,    .   UL 21, 811, 819
       exsection of the, .     .     .  U 329
       cases of exsection,      i.  347, iL 374
           see Lower Jaw.
       superior,  or upper  jaw,  ex-
         section of)     .    .    .  iL 375
           Appendix L 1.
       fissure of,  .     .     .    . UL   13
Maxillary sinus, diseases of)  .     . iii.   93
         foreign bodies in,         . UL   96
         osseous cysts and  tumors
           of,                    . iu.   99
         perforation of, .    .    . iiL   93
         polypi  of) .     .     .     . UL   97
Meatus auditorius externus,   .     . iii. 101
           see Ear.
       of urethra, contraction of,  . iu. 730
         in women,     .     .     . UL 371
Meches or tents,   .    .     .    .   i. 104
Median lithotomy, .     .     .     .iii. 573
       nerve, excision of)     .    .  ii.   48
         neuromas of)  .     .     .  U. 615
       and median cephaUc veins,  .   L 237
       venesection in,   .     .     .      ih.
Mediastinal tumors,     .     .     .  ii. 671
Melanosis,.....ii. 694
       of parotid gland, .     .     . iii. 123
Melicerous tumors,      .     .    .  U. 762
Membrana tympani,  perforation of,  iii. 108
Meningeal artery, Ugature of)      .  iL 613
Metacarpus, amputation of)   .     .  u. 147
       trephining of,                U. 542
Metacarpal articulation, excision of)  ii. 444
Metallic ligatures of arteries,  .    .   L 715
       cauteries,   .     .     .     .   L 302
Metastalic abscesses,   .     .     .   i.   80
Metatarsus, amputation of,    .     .  U. 195
       division of its tendons,      .   L 416
       exsection of)     .     .  U. 423, 478
       trephining of,    .     .     .  U. 541
Method, circular, of amputation,    .  U.   99
       oval,.....U 108
      of performing, surgicaJ,      L 6, 891
Metopoplasty,  or  anaplasty  of  the
         forehead,     .     .     .   i. 633
Milky  cataract—see  Cataract,    . ii. 841,
                                  Ui. 850
Minor surgery, the  art of dressing,
         with various instruments,
         bandages, &c,      .  L 38—233
Mother's  marks—see  Naevi  Mater-
         ni,.....U. 553
Mons veneris, abscesses and tumors
         of the,    .    .    .     . Ui. 450
Morbid cicatrices from burns, &c.   .  i. 377
Mouth, atresia and contraction of,  . iii.  19
      diseases and operations od,  . Ui.   1
      too large  an opening of the,   iii.  21
      speculum for the,     .   Ui. 52, 935
      tumors of the,   .    .     . UL  39 
978
INDEX.
 Moral  precautions regarding  sur-
         gical operations,    .    .   L  11
 Mortahty of amputations,  statistics
         of).....U 133
       Uthotomy,   .    .    .     .  Ui. 916
       Uthotrity,   ....  iii. 918
           see Statistics.
 Mortification, amputation in cases of)
                                ii.  61—64
       bleeding in certain cases of)   u. 128
           see Gangrene.
 Moulding tablets for fractures,     .   i. 125
 Moxa and various cauteries,    i. 294—302
 Muscles of the orbit,    .    .     .   L 508
       table of) in English and French.
         Appendix i. xiv.—xxiv.
       of the palate, their division in
         cases  of  cleft  palate—see
         Staphyloraphy,     .     .  Ui.  71
Musculo cutaneous  nerve, neuromas
         of).....U. 614
MusUn and calico dressings,  .     .   i. 111
       bandages,    .    .    .     .   i. 118
Mylo hyoid tumors,     .    .     .  ii. 600
Myotomy and tenotomy,   i. 428, 473, 501,
                                   Ui. 942
           Appendix to vol. i. liu.
       and tenotomy in America,     i. 501
Myopia, or short-sightedness after the
         operation of strabismus,   .   i. 543
       section of different muscles of
         the eye, to relieve,  .     .   i. 545

                    N
Naevus maternus, or  aneurism  by
         ganastomosis, or erectile tis-
         sue,      .    .   ii. 57, 298, 553
           see  Appendix i. liii.
       treatment  by couching needles,
                                   ii. 583
       by ligatures,     .    .     .  ii. 560
       by Ugating the arteries of the
         part,     .    .     .     .  ii. 570
       by red-hot needles,    .     .  ii. 580
       see Erectile tumors,   .  UL 553, 580
Nails, diseases of the,   .    .     .   i. 359
 Nail, in the flesh,  .    .    .  L 359—375
 Nares, contraction and occlusion of)  ii. 782
Nasal canal,.....U. 783
       operation,  for removal of a
         large tumor,   .    .     .  U. 383
       fossae, calcuU in, .    .     .  iii.  88
       foreign bodies in,      .     .  iL  72
       hemorrhage from,     .     .  UL  74
       polypi of)    .    .    .     .  iii.  75
       polypi of frontal sinus,     .  Ui.  90
 Nasi septum, hypertrophy of)     .  Ui. 932
 Nature of operations,   .    .    .   i.   4
 Neck, bandages for the,  .    .  L 163, 193
       bleeding in the,   .    .    .   L 254
       cicatrices of the,  .         ..   L 396
       fatty tumors  of the,   .    .  ii. 625
       ligature of arteries of the—see
         Arteries,  ...    .   L 850
       lymphatic tumors of the,   .  ii. 598
       nerves of the,   .    .    .  ii.  39
         operations on the,  .    .  u.  47
                                     PAOl
Neck—continued.
       neuromas of the, .     .     .  ii. 617
       operations on the,     .     .  iii. 115
       operations on tho air passages,
                                   iii. 136
       ligature of arteries  of the,   .   i. 850
       on the cesophagus,     .     .  UL 157
       on the salivary glands,     .  iU. 115
       on the thyroid gland,  ,     .  Ui. 128
       tracheotomy and laryngotomy,
                                   Ui. 143
       surgical of the humerus,  its
         exsection,     .     .     .  U. 288
       of the femur, fractures of,   .  Ui. 893
       of the uterus, cancer of,  Ui. 498, 538
Necrosis, amputation for,     .    ii.  77—87
       of the cranium,  .     .    u.  72, 772
       exsection in cases of necrosis,
                                   u. 324
Needle used in vesico-vaginal  fistu-
         las, .....iiL 880
       (American) aneurismal,     .  -i. 917
Needles and thread,    .     .     .   i.  99
       cataract,    .    .     .     .  iii. 850
       exploring,  .    .     .     .   i. 347
       and similar foreign bodies, how
         extracted,     .     U. 743, iii. 168
       red hot, in the treatment of
         naevi, materni, &c,  .  U. 298, 560
Neuromas,
       deep-seated,
       superficial,  .
Nephrotomy, .
Nerves, operations on,
       amputation for injuries of,
       excision of the nervous  ex-
         tremities in cicatrices,
       gangUonic transformations of
         the,      .     .     .     .  ii.  56
       substitutions, nervous,    U.  57, 583
	. ii. 613
	. u. 614
	. U. 613
, ,	. ii. 691
	. ii. 39
juries of,	. iL 56
55
in particular,	ii.	52
anterior and posterior tibial,	ii.	52
of the cranium, .	ii.	39
cutaneous, of the elbow,	iL	50
dental, .	i.	41
of elbow, .	ii.	50
external saphena,	ii.	51
of face, .	iL	40
of facial or portio dura,	ii.	45
of fore-arm,	ii.	48
frontal, .	U.	40
of head and neck,	U	39
gustatory, . . . .	ii.	46
inferior maxillary,	U.	45
infra orbitar,	L	41
internal saphena,	u.	51
of leg,.....	iL	51
median, .	i.	48
of neck, . . . .	iL	47
ulnar,.....	i.	40
puncture of) in venesection,	i.	249
pneumagastric, divided, re		
covery from,	ii.	47
radial, . . . .	L	50
saphena, .	ii.	61
sciatic, .	iL	53
of thigh, .		ib.
 
INDEX.
979
Nervous accidents during operations,  L  26
Neuralgia,.....U  39
       acupuncture in,  .    .    .   i.  56
       compression of arteries in,  .   i. 679
       electro-puncture in,   .    .  iL  55
       exsection  of nerves in cica-
         trices in,  .    .    .    .  ii.  56
       ligature of carotid, in cases of,  i. 874
       operations for,   .     .    .  iL  39
           Appendix i. Ii.
       orbit,  of the nerves of)      .   i. 508
       from puncture of the nerves,
         in venesection,      .    .   i. 249
Neuromatic tumors, or neuromas, iL  607—
                                      613
NUe, climate of the—Appendix i. xlvi.
Nippers—see Forceps and Exsections.
Nitrate acid of mercury,      .    .   i. 295
       of sUver,    .     .     .    .   i. 295
         in strictures of the urethra, iii. 732
Nitric acid, as a caustic,       .    .   i. 298
           see Caustics.
Nitrous oxyd gas as an anaesthetic,  UL 823
Non-consolidated fractures, exsection
         in......ii. 298
Nose, anaplasty of the, .   i. 552, 555, 573
       bandages  for the,       .    .   L 158
       cancerous tumors of the,   .  U. 778
       elephantine tumors of the,  .   ii. 779
       foreign bodies iu the,  .    .  UL  74
       occlusion  and contraction of
          the,.....U. 782
       nearly severed united, .    .   i. 552
       operations on the,      .    .   ii. 777
       polypi of the,    .     .    .  iiL  74
       sebaceous tumors of the,   .  U. 643
       remarkable case of and opera-
          tion,      .    .    .    .   ii. 644
       tumors of the septum of the,   ii. 781
Nostril, calculi of,  .    .     .    .  iii.  72
       foreign bodies in,.     .    .  iii.  74
       hemorrhage from,      .    .  Ui.  74
       hypertrophy of septum of)  .  iiL 934
       polypi of)    .    .     .    .  iiL  75
       removal of a large tumor from,  u. 383
           see also Nose and Nasal fossae.
Nymphae, diseases of and operations
         upon the,     .     .    .iii. 453
Nystagmus, or trembling of the eyes,
         after the operation of stra-
         bismus.....i 544
       muscles of the eye to reheve
         this disease,   .     .    .   L 547
ObUteration of arteries by Ugature,   L 719
       of veins,     •     •    •    . ii.   2
       of vagina,   .     .    . iii 462, 950
       of the vulva,     .    .    . Ui 530
Obturators in cleft palate,    .    .  iii  70
       artery,  its relation to femoral
         hernia,    .    .    •    .  Ui 357
       or thyroid hernia,     .    .  iiL 372
Occlusion of the vagina,  .     . Ui. 461, 950
       and contraction of the nares,  ii. 782
       of the neck of the uterus, ui. 462, 913
Occipital artery,   .    .    .    .  i 848
74
90
Occipital artery, compression of)    .  i 641
CEdematous laryngitis, tracheotomy
         for,.....Ui 136
Ointments or cerates,    .     .     .  i 112
CEsophagus, catheterism of)  .     . iii 157
       contraction of,        .     . Ui. 159
       foreign bodies in,   Ui. 139, 162, 168
       tracheotomy in cases of for-
         eign bodies,    .     .     . UL 139
(Esophagotomy,        .     . Ui. 165, 919
Olecranon, bandages for its fracture,  L 184
       excision of, .     .    .     .  ii. 405
       hematic  cysts of) .     .     .  U 652
Olfactory apparatus, operations upon, UL   72
       foreign  bodies  in  the nasal
         fossae,    .    .     .     . UL   72
       calculi in.....UL   88
       hemorrhage from,     .     . iii.
       polypi of)   .     .     .    UL 75,
         of frontal sinus,     .     . iu.
           see Nose and Nasal Fossae.
OUve oil, its effect in reUeving symp-
         toms of suffocation,       . iii. 153
Omental hernia,   .    .     .     . Ui. 232
Onyx,......U. 898
Opacity of the  cornea,  and its abra-
         sion for the cure of) .
       of the lens or cataract,
Opening of the mouth  too large,
         contraction of, .
           see Mouth.
Openings, hernial, .
Opiates in hernia, .
Operations, anaesthesia in,
       in general,  .
       nature of)
       general considerations  upon
         the nature,  conditions,  in-
         dications, and precautions
         necessary in, the  instru-
         ments used, accidents  that
         may occur, the results, sub-
         sequent   treatment,    the
         dressings, arrest of hemor-
u	911
in.	851
iu.	21
m.	19
UL	218
UL	248
UL	821
1.	2
         rhage, &c.     .    .    L 4—67
Operations, speciaL
         anaplasty,     .     .  L 550—662
         upon the abdomen,  .     . UL 195
         amputations,   .     .     .  ii.  58
         upon the arteries,   .     .  i. 662
         for aneurisms,  .     .     .  i. 665
         of bleeding, or vensection,  L 240
         for removal of the breast,  UL 176
         Caesarean section,   .     . Ui. 548
         castration,     .     .     . Ui. 421
         on the cheeks, .     .     . UL  23
         on the chest,   .     .     . Ui. 170
         removal of deformities,    .  i. 377
         on the ear,     .     .     . UL 100
         for emphysema,     .     . UL 858
         for empyema,  .     .     . UL 187
         for   extraction  of  foreign
          bodies, .     .     .     .  u. 748
         on the face,    .     .     .  ii. 777
         on the fauces,  .     .     . iiL  49
         on   female  sexual  organs
                             UL 450—559 
980
INDEX.
 _     •                             PAGE
 Operations, special—continued.
          femoral hernia,      .     . Hi. 359
          fistulas in ano, .     .     . hi. 799
          on the head,   .     .     .  U. 755
          on the hand—see Hand.
          hernia,  strangulated,     . UL 215
          hydrocele,     .     .     . hi. 391
          inguinal hernia,     .     . Ui. 346
          larynx and trachea, .     . Ui. 136
          1'PS,      .    .     .     . UL   1
          lithotomy,     .     .     . Ui. 568
          maxillary sinus,     .     . iii.  93
          mammary gland,    .     . iii. 176
          mouth,   .    .     .     . iu.   1
          nasal fossae,   .     .     . iii.  72
          neck,    .... iii. 115
          nose,    .    .     .  U.  383, 777
       cesophagotomy,  .     . UL  165, 919
       paracentesis of the abdomen,
                              ui.  195, 206
          of the eye,     .     .    . iL 899
          of the liver,   .     .     . iii. 918
          of the thorax,  .     . Ui.  187, 858
          of the pericardium,  . iii.  192, 927
       on the palate,    .      .    . iL  49
       on the penis,    .     . Ui. 437, 903
       for phlebotomy,  .     .    .  i. 236
       on the saUvary glands,     . iii. 115
       for strabismus,   .     .    .  L 511
       for strangulated hernia,     . iii. 253
       for symphysiotomy,   .    . Ui. 549
       on the teeth,     .     .    .  i. 316
       on the thorax—see Thorax
       on the tonsils,    .     .    . Ui.  49
       for removal of tumors, .    . iL 548
       on the tongue,   .     .    . UL  40
       of trephining,    .     .    . ii. 509
       of tracheotomy,  .     . Ui. 144, 841
       for umbilical hernia,   .    . iU. 368
       for removing uterine polypi   U. 491
       of vaginal uterotomy,  .    . Ui. 554
       for varices,  .     .     .    . U.   2
       on the veins,     .      .    . U.   1
       on ventral hernias,     .    . Ui. 371
       on vesico-vaginal fistulas,  .  i. 624,
                         UL 521, 874—887
           Appendix i.  lx.
Ophthalmia, cauterization  of the nasal
         membrane,  in cases of)   . ii. 911
Opthalmoscope,    .     .     .    . iU. 921
Orbit, aponeurosis of)    .     .    .  i. 509
       cancer of,        .    .    . U. 905
       muscles of,  .     .     .    .  i. 508
       nerves of,        .     .    ,  i. 508
       vessels of)   .     .     .    .  i. 509
Orbitar cavity, cancers of)     .    . ii. 905
         erectile tumors of)   .    . ii. *567
         exsection of bones of)    . U. 327
         Ugature  of  arteries, in a
           case of erectUe tumor of
           the orbit,    .     .     .  iL 572
         tumors of the orbit,  .     .  ii. 834
Orchitis,  incisions, into  the  tunica
         albuginea, in cases  of in-
         flamed testis,  .     .    .iii. 432
Organs of generation in the male, . Hi. 375
           in the female,     .    . UL 450
 Organic changes in the system,  from
         amputation,   .    .    .  iL 130
       lesions of bones, exsection for,
                                    ii. 324
       plugs, for the radical cure of
         hernia,  .... iii. 224
 Organs, restitution of,   .    .    .  L 650
           see Anaplasty.
 Oris, speculum,    .... iu.  52
 Os calcis,  exsection of)  .   * .    .  ii. 423
 Osseous cysts, generally,     .    .  iL 670
       cysts  and tumors  of the an-
         trum,    .... iii.  99
       plate,  in the diaphragm,    .  U. 671
 Ossification of the  lens, .    .    .  i. 884
 Osteo-sarcoma,  successful  exsection
         of the lower jaw, for,     .  ii 347
       cases of,               Ui. 347—374
       exsection of the clavicle, for,   ii. 409
       cases of,    .     .     . iL 410—418
 Osteotomes, or boue-cutters,  .    .  H. 281
 Otoplasty—see Anaplasty of the ear,  L 571
 Otoraphy, or suture  of the  external
         ear,.....iiL 100
 Ovarian cysts and  tumors,  operation
         on,                 .     . iL 208
       tumors, extirpation of,  Hi. 208—213
Ovariotomy, statistics of,     .     .  UL 922
Oval method of amputations, .     .  H. 108
Paddings in bandaging, .    .    .  L 145
Pain, how  prevented by anaesthetic
         agents,   .    .    i.   22, in. 821
           see Chloroform and Ether.
       after amputation,     .    .   U. 119
Painful subcutaneous tumors,     .   ii. 608
Palate, artificial,   .    .    .     .   H.  72
       cleft, division of its muscles,
         in,.....Hi.  71
       fissures of)  .    .    .     .  iu.  49
       see Staphyloraphy,    .     .  Hi.  60
       also Tonsils,     .    .    .  Ui.  49
       substitute for,    .    .     .  UL  72
Palatoplasty—see Anaplasty,    i. 607, 657
Palm of the hand, aneurisms of)   .   L 900
         wounds of,    .    .     .      ib.
Palpetrse—see EyeUds, .    .    .   ii 815
Pannus,.....iL 840
Par, vagum, its division and recovery
         from.....ii.  47
Paracentesis of the abdomen, .     .  Ui. 195
       accidents from,   .     .     .  Ui. 206
       of the eye,  .    .    .        ^ 899
       of hydrocephalus,     '.     '.  iii. 908
        Au* Uver'      •     •     •  iu- 918
       of the pericardium,    .  Hi. 192  927
      of the thorax,    .     .  Hi. 187,' 858
       wounds  of intercostal artery
        mi.....UL 190
      statistical table  of  cases of
        of thorax,     .     .     .  UL 858
          see Statistics.
Paralysis of the bladder after Uthot-
        om7>     •     •     •     .  UL 609
Paralysed or useless limbs, amputa-
        tioQof)   .     .     .    .  U.  84 
INDEX
981
Paraphymosis,      .... iii. 441
Parotid gland, extirpation of, UL 120—127
           Appendix L 1.
         fistulas of)                iii.  26
         tumors of,    .    u. 598, UL 115
Parts destroyed, restoration of,     .  L 550
Parturition difficult,    .    .     .iiL 545
       symphysiotomy in,    .     .     ib.
       Caesarean section, •    .     . iiL 548
       vaginal uterotomy,    .     . Hi. 554
       rupture of uterus in,  .     . iu. 555
Passages, air, operations on, .     . UL 136
       tracheotomy,    .    .     . Hi.. 150
       alimentary,  .... Hi. 157
       lachrymal,  .    .    .     .  ii. 783
PateUa, apparatus in, fracture of the, Hi. 897
       bandages for fracture of)    .  i. 188
       bursal tumors of)      .     .  ii. 680
       exostosis of)                 ii. 722
       exsection of)    .    .     .  H. 502
       fracture of,  .     L 782, 423, iii. 896
       adhesive strips in fracture,  . iii. 897
       hematic cysts of) .     .     .  H. 656
Patient, the position of in surgical
         operations,     .     .     .  i.   18
Pea issues,   .     .    .     .     .  L 288
Peas, stones, and other foreign bodies
         in the nose,   .     .     . UL   72
Pelotes,......L 103
Pectoroplasty,     .     .     .     .  L 645
Pelvis, bandages for,    .     .   L 169, 196
       exsection of parts of the, H. 298, 397
       exostosis,   .     .     .     .  ii. 718
       trephining of)                ii. 546
Penis, amputation of,   .     .     . ui. 446
       arteries of the,   .     .     .  L 890
       bandages,   .    .     .    .   L 171
       diseases of) and operations on
         the.....iu 437, 923
       elephantiasis of)  .     .    .  iii.  42
       rupture of)  .    .     .    . Hi. 324
       strangulation of, .     .     . iu. 443
       and scrotum, anaplasty of)  .  L 621
Penoplasty,   or  anaplasty  of  the
         penis,     .    .    L 645, Ui. 923
Percussion of synovial cysts,  .     .  iL 655
       in lithotrity,     .     . UL 670, 932
Perforated linen,   .    .     .     .  L 112
Perforation of bone, in anchylosis of
         knee-joint,     .     .     .Hi. 822
       of the femur, for anchylosis, . Hi. 821
       of intestine,     .      iiL 312—321
       of intestine in hernia,  .     . HL 286
       of the membrana tympani, Ui. 108, 946
       of the mastoid ceUs,   .     . Ui. 110
Pericardium, paracentesis of, . iiL 192, 927
Perinaeal bandages,     .     L 170, iiL 373
       fissures and ruptures,  .     . iii. 538
       hernia,      .... iii. 373
       accidents in,     ... Hi. 606
       lithotomy,   .     .     .     . UL 569
       incision  to reUeve  distended
         bladder,  .... iii. 839
       puncture,   .     .       iii 743—749
       section,     .    .     -iiL 722, 939
Perinaeum, anaplasty of, .     .     .  i 628
Peritonaeal hydropic tumors,  .     .  U 673
Peritonaeum, injury of) in Uthotomy, Ui 639
Peritonitis in strangulated hernia,  .  iiL 237
Period of amputation,   .    .     .  ii.  89
Peronei tendons, division of)  .   i. 417, 452
Pessaries of uterus and vagina,     .  HL 471
Pesequinus, tenotomy of)  i. 418—445, 501
Petrous portion of temporal bone, its
         fracture,  .     .    .     . U. 526
Phalanges of fingers and toes, ampu-
         tation of)       .    .   H. 136, 193
Pharyngeal artery, Ugature of)     .  i. 856
       fistulas,    .     .    .     .  Ui. 156
Pharynx,  foreign bodies in,        .Hi. 156
Phlebitis,     .    .     .    .  L 75, iL 129
       after Ugature of arteries,     .  i. 746
       after venesection,     .     .   L 251
Phlebotomy,.....L 236
Phymosis,.....Hi. 437
Piles, or hemorrhoids,   .    .     .  iii. 771
Pins, hair pins in  the  bladder, how
         extracted,      .    .     . UL 840
       and needles as foreign bodies, ii. 743
       in  un-united fractures, .     . H. 309
       and setons in aneurisms,   .  i. 725
Place of amputation,   .    .     .  iL  94
Plastic surgery in America,  .     .  L 628
       surgery, in general,   .     .  L 650
            see Anaplasty.
Plantar arteries, wounds of)  .     .  i. 907
Plasters,.....L 205
       adhesive,   .     .    .     .  i. 127
Plaster of Paris, in fractures, .     .  i. 125
Platysma nyoids, its section, .    .  L 473
Pledgets of lint,    .    .    .   i. 101, 628
Plugs or tampons, .     .    .     .  i. 104
Plugs, organic, in hernia,    .     . U 224
Plugging of arteries  in  aneurisms—
          see Aneurisms.
       of arteries,  .     .    .     .  L  47
       of the nostrils,    .    .    . HL  74
       or filling teeth,   .    .     .  L 319
Pneumogastric  nerve, recovery from
          its division,    .    .     . U.  47
Pocket case,.....L  90
       handkerchiefs as bandages ip
          fractures,  &c,  .    .     .  i. 191
Polypi of the ear,  .     .    . iii. 106, 928
       of the eye, after the operation
          of strabismus,  .    .    .  i. 526
       of female urethra,    .     . UL 741
       of frontal sinus,   .    .     . HL  91
       of the  glottis,    .    .     . Hi. 155
       of lachrymal,     .    .     . H. 787
       of the maxillary sinus,     . HL  96
       of the nasal fossae,    .     . iii.  75
       of the nose,  .     .    .    . HL  75
       of the rectum,    .    .    767—776
       of the urethra, male,  .     . iii. 742
       of the urethra, female,     . iH. 741
       of uterus,    .     .    .Hi. 47 8—498
       of vellum palati  •    •     • iii-  88
Pomades in dressing,    .    .    i. 103, 203
Popliteal aneurism,      .   i. 768, 901, 774
       treated by compression,     .  L 702
       artery, compression of)      .  L 686
       artery, ligature of,    .   L 768, 907
            see Arteries and Aneurisms. 
982
INDEX.
Porte crayon, . . . . i.	PAG* 94
meche, . . . . L	98
Portio dura nerve, . . . . iL	45
Position of the bistoury and knives, L	328
in hernia, . . . . iU	245
of patient, and of the assist-	
ants in operations, . . i.	18
Posterior fauces, . . . . Hi.	49
tibial artery, . . . L	763
nerve, . . . . ii.	52
artery, Ugature of) in wounds, i.	762
Posthioplasty, or anaplasty of the	
prepuce, . . . . i.	657
Poultices,.....i.	211
Potash issues, . . . . i.	287
Potential cautery, . . . L	294
Precautions in dressing, . . . i.	229
in operations, . . i. 7-	-13
Preface of the translator—Appendix,	
vol. i.—vii.	
. to the first edition of this work	
—Appendix, voL ix.—xviU.	
to the first edition by the	
author—Appendix, voL i.	
--XXXV.	
to the second edition by the	
author, voL L, xxxix.	
Pregnancy, lithotomy in, . . Ui.	915
aneurism in, ... i.	775
its effects on un-united frac-	
tures, . . . . ii.	299
Preparations for amputation, . . ii.	95
Prepuce, adhesion  of) to the  glans
         penis.....HL 444
       destruction of,   .    .     .  iU. 445
Pressure in the treatment of  aneu-
         risms,              .   i. 694, 702
Primitive Uiac, first case of its Uga-
         ture for aneurism,   .     .   L 941
       iliac, operations on,    .     801, 903
Presse artere,     .    .    .     .   i. 679
Prevention of pain in surgical opera-
         tions,    .    .      i. 22,  Hi. 821
           see Chloroform and Ether.
Probes,......i.  90
Probangs,.....HL 164
Prognosis of amputations,    .     .   H. 131
Prolapsus ani,     .    .    .     .  UL 775
       reduction  of)                    ib.
       cauterization of,  .    .     .  Hi. 779
       extirpation of)   .    .     .  iii. 776
       of the iris.....U. 883
       of the uterus,    .    .     .Hi. 465
Provisional dressing for fractures,  .   i. 191
Prostate gland, calculi in,    .     .  Hi. 694
Protrusion of bone,  after amputation, H. 122
Prostration, excessive, a counter in-
       dication to amputation,     .  ii.  87
Pseudarthrosis,    .    .    .     .   ii. 298
       exsection for,    .    .     .   ii. 305
       ivory pegs in,                    ib.
       see Joints false and artificiai   ii. 302
Pseudo-cancerous tumors,    .     .   ii 710
Phthisis laryngeal,  tracheotomy  in
         cases of) .    .    .     •  iji 141
Pterygion,.....ii 839
Pubes, exsection of,    .    .    .   ii 400
                                     PAG*
Pubis, division of symphisis of,     . Hi. 545
Puerperal convulsions, tracheotomy
         in,.....iii. 845
Puckers in bandages,   .    .      .  ]• 114
Pudenda, varicose veins of)   .     . iL  21
Pulmonary artery, aneurisms of—see
         Aneurisms.
       phthisis, fistula in ano in,    . HL 803
       phthisis, a counter indication
         to amputation, .    .      . ii.  87
Puncta lachrymalia,    .    .      . ii. 785
Punctures in general,   .    .      .  i 346
       of the bladder,   .    .  Hi. 743, 838
       of the  bladder through  the
         rectum,  .    .    .      . Hi 745
       of the eye—see Eye.
       perinaeai   .    .    .      .Hi. 743
       of the cranium,  in  cases of
         hydrocephalus,     ii 765, iu. 907
       subcutaneous, of synovial cysts, ii. 666
       of the uterus,    .    .      .Hi. 462
       various kinds of) .    .      .  i 346
Punk and agaric, in dressings,    i 110, 116
Pupil, artificial,   .    .    .      . H. 886
       Appendix, vol. i, p. 1H.
       immobUity  of,   .    .      . H. 844
       size of, in cataract,    .      . Ui. 852
Purgatives, in strangulated hernia,  Ui. 247
Purulent cataract, .    .     .     . iL 856
       infection,   .    .    .  L 75, ii. 129
Pus, effusion of) in the thorax,      . Ui 180

                    R
Rabid animals, amputation  in  cases
         of bites from,  .    .      . iL  82
Rachidian and dorsal myotomy,   . iiL 385
Radial artery, compression of)      .  L 683
       case of false aneurism of)    .  i. 699
       artery, ligature of,    .      .  i. 811
       nerve, excision of,     .      . U.  50
Radical cure of hernia, .  Ui. 220, 353, 906
       cure of hydrocele,     .      . Ui. 385
       excision of)                 . iL 406
       fracture of, .    .    .      .in 892
Railroad injuries, treatment of)      . ii.  76
Ranula, anaplasty for,  .    .     .  i. 641
       operation for cure of)  .   iii. 33, 929
Rasping in un-united fractures,     . ii. 303
Razors in dressing,     .    .      .  i.  93
Reclination of cataract, .    .   '  . U. 859
Rectoplasty,.....iii. 930
Recto-vaginal fistulas, .    . iii. 554, 867
       vesical anaplasty,     .     .  i. 627
       vesical fistulas,   .    .  iii. 751, 867
         puncture,      .    .  Hi. 748, 754
       vesical Uthotomy,     .     . iii. 609
       statistics of this operation,  . Hi. 675
       vesical puncture of the blad-
         der.     •    .    . iii. 745—754
Rectum, abscesses of,        .     . iii. 930
       remarkable case of)   .     . iii. 930
       anaplasty of,                i£i. 930
       calcuh of)  .    .    .     . Hi. 769
       diseases of) .    .    .      . ijj. 757
       defects of conformation,     . iii. 757
       extraction  of foreign  bodies
         from>    •    •    .      . iU. 768 
INDEX.
983
Rectum—continued.
       extirpation of)        .    . HL 930
       hemorrhoidal tumors of)    . HL 771
       imperforate,     .    .    . iii. 757
       polypi of)        .    .    .HL 770
       puncture of bladder through
         the,.....Hi. 745
       strictures of,      ... iU. 765
Rectus femoris, accidental division,
         or rupture of,  .     .     .  L 423
       muscle of the eye, its division.
         see Strabismus.
Reduction Of dislocations,  by a new
         method,   .     .     .     .Hi. 853
Reducible large inguinal hernia, suc-
         atessfuUy operated on,     . iii. 354
Reduction of an inguinal hernia, after
         Jiivision  of the  stricture.
         /see Inguinal hernia, .     . Ui. 350
       of prolapsus ani,  .     .     . iiL 775
       oT uterus and vagina,  .     . Hi. 470
Red hoji needles, in the  treatment of
       ,   najvi materni,  .     .     .   i. 298
       /pins, in the treatment of warts, i. 360
Redreesers of the head,  .    .     .  i. 164
Reduction of hernia, or the taxis, HL 232, 268
            see Hernia.
Refrigerants and  styptics in lesions
          of arteries,    .     .     .   i.  676
        in  the  treatment of strangu-
          lated hernia,  .     .     .Hi. 250
Regimen after operations,    .     L 63, 634
Region carotid, tumors of)   .     .  ii. 602
        supra clavicular, .     .     .  ii. 604
 Resection of bones—see Exsections,  ii. 281
 Restitution or restoration of destroyed
          parts—see Anaplasty,    .  i. 550
        surgical,     .    .    .    .  ii. 275
 Retraction of tendons or muscles, .  i. 426
 Retractor,.....ii. 103
 Retroversion of the uterus,  .    . iii. 464
 Reversion or prolapsus of tho vagina, iii. 465
 Reversion of the tongue,     .    . Hi.  42
 Revulsives,.....L 285
 Rhinolites,  or calculi  of the nasal
          fossae,    .... iii.  89
 Rhinoplasty in America,     .    .  i 585
        see Anaplasty of the nose,  L 573—
                              585, 638, 646
             see also Appendix i.  xliv.
 Rhinoraphy,.....ii. 785
 Ribs, bandages for fractures of the,   i. 187
        exsection of,    ...  H. 393
        remarkable cases of exsection
          of,.....|i 395
        trephining of)                 H. 540
 Rings, hernial,     .    .    .    . Hi. 219
 Rolls or dossils of Unt,  .   .     .  L 102
 Roller bandages,   .    .    .     .  i. 140
 Rope, twisted, its use in dislocations, iii 854
 Rubefacients,       .
 Rules for bandaging,   .    .
 Runaround and diseases of the naUs,
 Rupture of the trachial artery,
        of the heart,
        of a hernial sac,  .
Rupture—continued.
       of the perinaeum,
       of the uterus,
       or hernia,
       alterations of,
       artificial anus in,
       crural hernia,
of the penis,
 l 278
 i 146
 L 363
 i. 880
 L 750
iU. 339
iiL 924
                              PAQ*

                          . iiL 543
                          . Hi. 555
                          . HL 215
                          . HL 270
                          . UL 293
                          . Ui. 354
epiplocele, or omental hernia, UL 270
enterotomy in cases of ObUt-
  eration of intestine,  .     . Hi. 318
gangrene, with hernia,.     . UL 283
gastrotomy in cases of)     . HL 319
incision  or   division  of  the
  stricture without  opening
  the sac.....HL 263
inguinal hernia,  .     .     . iiL 323
intestine returned in mass, . iii. 278
internal strangulation,.     . HL 279
operation for strangulated her-
  nia, .....UL 250
radical cure of hernia, .     . Hi. 220
reduction of hernia,   .     . UL 268
state of sac, when strangulated,
                            iii. 257
statistics of hernia,     .     . iii 375
strangulated hernia,.  .     . Hi. 233
umbUical hernia,      .     . iii. 365
ventral and other varieties^  iii. 371
wounds of intestine Hi hernia, HL 295
     see Hernia.
of the corpora cavernosa penis, Hi. 924
of the perinaeum, .     .     . HL   54
of the uterus,    .     .     •  Hi. 555
Sac aneurismal—see Aneurism,   .  l 665
       changes in the, after Ugature
         of the artery,  .     .     .  i. 745
       gangrene of the,  .     .   L 667, 744
       hemorrhage and other  acci-
         dents after ligature of the
         artery,   .    .     .     .  L 746
       hernial,    .    .     .  iii. 217, 331
       its state when strangulated,  HL 257
       hydropsy of a hernial, .     . UL 257
       how to distinguish the intes-
         tine in a hernial,    .     . ih\ 259
       incision of the stricture of the
         hernial,  .    .     .     . HL 263
       viscera adherent within the, HL 252
Sacrum  and  coccyx, exsection of
         portions of)         .     .  iL 392
SaHvary fistulas,   .    .     .     . iiL   26
       gland, submaxiUary, obstruc-
         tion of its duct,     .     . Ui.   33
       regions, tumors of,    .     . HL 115
       tumor of parotid,      .     .      ib.
       extirpation of parotid, .     . Hi. 119
       case of extirpation,    .     . HL 123
       submaxillary gland, its extir-
         pation,   .    .     .     . ui. 127
       submaxillary tumors,  .     .  iL 598
Sanguineous emissions or bleeding,   i. 235
       tumors,    .    .     .     .  H. 684
       of the  cranium,  .     .     .  ii. 769
Saphena nerve,    .    .     .     .  ii.   51
       veins, bleeding in,     .     .   i. 260 
984
INDEX.
                                      PAGE
 Sarcocele......Hi. 429
 Saturated dressings,     .     .     .  i. 215
 Saving of limbs, from amputation,  .  iL 271
 Saws, chain,.....H. 282
       vertical,     ....     ib.
       various kinds of—see Exsec-
         tions,     .     .     .     .  ii. 281
            see Amputations and the Atlas.
 Scaleni muscles, Ugature of the sub-
         clavian artery within the
         scaleni,   .     .     .     .  i. 834
       statistics of these cases,     .  i. 837
 Scalp, cirsoid aneurism of,    .     .  U. 573
       cartilaginous tumor of,      .  H. 671
       wounds of,  .     .     .     .  ii. 535
 Scapula, amputation of)  .     .     .  U. 185
       avulsion  of the scapula  and
         arm,     .    .    .    . iL 188
         exsections of the scapula,   iL 418
       exostosis of the scapula,     .  H. 721
       hematic cysts in the  scapular
         region,    .    .     .     .  ii. 652
       synovial cysts in, .     .     .  U. 652
       trephining the scapula,      . H  547
 Scarified cupping   .    .     .     .  i. 274
 Scarification, cupping by,     .     .  i. 271
       for radical cure of hernia,   . Ui. 224
Scarifications  and incisions  in stric-
         ture of the urethra,  .    . iii. 719
Scarfs,......i.  98
Schirrous tumors,  .    .     .    . H  694
         of the brain,   .     .     .  i. 714
Sciatic nerve,  its divisions,   .    . ii.  54
         neuromas of,  .     .     . H. 616
Scissors in dressing,    .    .    .  i.  92
Sclerotomy, or extraction of cataract
         through the sclerotica,   . ii. 867
Scleritonyxis,     .    .    .    . U. 850
           see Cataract.
Screw instrument, used in immobiUty
         of the lower jaw,    .    . iii. 812
Scraped lint,.....i. 105
Scrotal hernia—see Inguinal hernia, iH. 323
       complicated with hydrocele, iii. 402
Scrotum bandages,      .     .  i. 173—176
       chronic diseases of the skin of
         the, with hydrocele,     . Ui. 402
       elephantiasis of the,   .    . iii. 419
       excision of the, for varicocele, ii.  33
       gangrene of the, in hydrocele,
         from injections,     .    . Hi. 394
Scrotal  tumor, containing debris of a
         foetus.....Hi. 433
       tumor, difficult diagnosis of,  Ui. 435
 Scrotum and penis, anaplasty of)    .  L 621
 Skull,  depressed  portions   of  the,
         raised by cupping    .     . iL 537
 Scultetus' bandage,      .     .     .  L 147
 Sebaceous tumors,  .     .     .     . H. 639
 Secondary amputations, .     .     . H.  90
 Section Caesarean,  statistics  of this
         operation,      .     .     .iii 911
 Section of the bone, in amputation, ii. 104
       of varices,   .     .     .     .  ii.  13
 Senulunar incisions of the face, iu ex-
         section of the lower jaw,  i p. ix.
 Separation of Hgatures from arteries,  i.  65
   i. 677
 iii. 451
 iii. 181
   i. 289
288, 725
 Separation  of bone, spontaneously,
         after amputation,    .     .  ii. 124
 Septum nasi,  hypertrophy of) .     . iii. 934
         tumors of,      •     •     •  ii. 781
 Sequestra  of  bones, removal of—see
         Exsections,    .     .     •  ii. 280
 Serres fines, to arrest hemorrhage,
 Sero mucous cysts of female labia,
 Serous effusions, in the thorax,
 Setons, in general, .
       in aneurisms,     .     .   i _-
       in cysts of the thyroid gland, iii. 943
       in erectile tumors,     .     .  iL 564
       in goitre,   .... iiL 128
       in hematic cysts, •     .     .  iL 647
       hydrocele,  .... iii. 386
       in inguinal hernia,     .     . Hi. 353
       in lymphatic tumors,   .     .  ii. 585
       in ranula,  .     .     .   iU. 36, 929
       in synovial cysts,      .     .  ii. 667
       in un-united fractures,.     .  ii. 300
       cases of)          .     .     .  H. 315
       in varices,  .     .     .     .  U.  14
Sexual organs,  in the male,  their
         diseases,  and  operations
         performed upon them,    . iU. 375
       castration,  .     .     .     . iii. 421
       organs, deformities of,  .     . Hi. 863
       organs, elephantiasis of)     . iU. 418
       hematocele, .     .     .     .Hi. 414
       hydrocele,.....HL 375
       penis, its diseases,     .     - HL 437
       organs in the female,   .     . Hi. 450
       cancer  of the uterus,   .     . iH. 498
       fistulas recto-vaginal, and ve-
         sico-vaginal,    .     . Hi. 521—545
       foreign bodies in the vagina
         and uterus,    .     .  iH. 476,803
       imperforate vulva,     .     . HL 458
       occlusion of the  neck of the
         uterus,   .... iii. 462
       parturition, difficult,    .     . Hi. 545
       perinaeum, fissures of)  .     . Hi. 638
       polypi of uterus,  .     .     . UL 468
       prolapsus of the vagina,     . HL 465
       prolapsus of the uterus,     . iii. 465
       retroversion of the uterus,   . iii. 464
      tumors of external organs,   . HL 450
Shampooing,.....i. 277
Shoulder, amputation of the,   ii. 185—193
       exsection of the scapula, ii. 291, 418,
                                      466
       exsection of the,.    .  u.  291, 466
       fatty tumors of the,   .    . ii. 626
      joint, amputation at the,     . ii. 173
      hemorrhage after this opera-
        tion,      .      .     .     . ii. 120
       ligature of the arteries of the,  i. 889
Silk in dressings,  .      .     .     .  L 110
Silver, nitrate of,  .      .     .     "  i. 294
Signs of stone,    .      .     .     . Hi. 561
Sinus, maxillare,  .      .     .     . HL  93
         perforation of)  .     .     . Hi.  93
       lateral, ulceration of)   .     .  L  34
       frontal  abscesses of,    .     .  ii. 773
       diseases of) .      .     .     .  ii. 771
       foreign bodies in,      .     .  iL 775 
INDEX.
985
_.                                   PAOB
emus, polypi of,   .     .    .     .Hi.  90
Skeleton, deformities, from alteration
         of the,   .     .    .     .  i. 484
Skin, foreign bodies in the,   .     .  i. 748
       needles and puis in the, ii 743, HL 168
       tumorsofthe,    .    .     . ii. 549
Solvents of urinary calculi   •     • m- Wl
Solution of cataract,     .    .     . Hi. 861
Soft cataract,.....iL 835
Sounds and catheters,  .    .     .  L  96
Sound uterine,.    .    .    .     . UL 948
       in lithotomy,     .    .     .Hi. 693
Spasms after amputation,    .     . U 119
       after operations, .    .     .  i.  65
       of the bladder after Uthotomy, Hi. 608
Spatulas,.....L  93
Special bandages,  .    .    .     .  i. 182
       operations,  .    .    .     .  i. 172
Speculum ocuU,   .    .    .      .  L 507
       oris,  .    .     .    .   HL 52, 935
       uteri.....Hi. 502, 558
       vagina,  for the operation  of
         vesico-vaginal fistulas,   . HL.874
Spermatozoa in the  fluid of hydro
         cele,
Spermatic cord, in hernia,
           see Hernia.
       hydrocele of)
       infiltration of)
Sphincter am, division of)
Spinal column, partial exsection of)
Spine, trephining of)
                                   iiL 414
                                   Hi. 333

                                   Hi. 406
                                       ib.
                               iH. 545, 785
                                    ii. 391
                                   iL 541
 Splints,......i. 132
       of gauze and felt,      .     . Hi. 888
 SpUnt holders,     .     .     .     .  i. 129
 Square bandages,  .     .     .     .  i. 149
 Squinting—see Strabismus,   i 503, iii. 938
 Spina bifida,       .     .    H.  767, iii. 935
       remarkable cases of)   .     . Hi. 810
 Spica bandages,    .     .     .     .  i. 178
 Sponge, its use in hemorrhages,    .  L 701
       as a dressing,          .     .  L 110
       sometimes a vehicle of con-
         tagion.....i. 128
 Spongio-piline,     .     .     .     .Hi. 938
 Spontaneous cure of aneurisms,    .  L 770
       separation of bone after am-
         putation,  .     .     .     . iL 124
 Squinting, or Strabismus,     .     .  L 601
 Stains on the skin,  or naevi materni, ii. 553
 Staphyloma,.....U. 902
 Staphyloraphy,    .... Hi.  60
       cauterization in, .    .    . Hi.  61
       division of the muscles of the
         palate in,       .     .     . HL  71
Staphyloplasty,  or anaplasty of tho
         velum palati and uvula,    i. 606
           see Appendix L, p. lx.
Starch bandages,   .     .     .     .  i. 123
State of the system, in surgical opera-
         tions, to be regarded,     .  i  13
Statistics of amputations,     .     . ii. 184
       of  their mortaUty,     .     . ii 133
       amputations at the hip-joint,  ii. 257
       amputations at the shoulder-
        joint, arm and thigh,      . iL 185
       amputations at the knee-joint, U 241
VOL.  III.
124
Statistics—continued.
       of aneurisms cirsoid,   .     .  U. 573
       of aneurisms of the arteria in-
         nominata,     .     .     .   L 876
       of  aneurisms  of the carotid
         treated by the distal method, i. 877
       of cancer of the breast,     .  H. 698t
       of cataract, .     .     .     .Hi. 850
       of Caesarean section,   .     . iii. 911
       of cirsoid aneurisms,   .     .  ii. 573
       of cures of fracture, and how
         often effected,  .     .     .Hi. 900
       of exsection of the elbow-joint, U 456
       of exsection of fractures,    . HL 900
       of exsection of lower jaw,   .  u. 339
       of fractures of the cranium, .  ii. 537
       of hernia,   .     .     .     . HL 374
       of the taxis, in hernia,      . UL 904
       of hypertrophy of the tongue, Hi. 942
       of  Ugature of the abdominal
         aorta,    .     .     .     .   i. 902
       of arteria innominata, .     .   i 881
       of Ugature of the carotid,    .   i 863
         of both carotids,     .     .   i 867
         of the common ihac,.     .   i. 803
         of external iliac,    .     .   i. 788
         of the femoral, .     .     .   i. 182
         of internal Uiac,     .     .   i. 794
         of the subclavian, without
           the scaleni  .     .     .   L 843
         of the  subclavian, within
           the scaleni  .     .     .   i. 837'
       of lithotomy,     .     .  Hi. 681, 916
       of Uthotomy and Uthotrity,  . Hi. 700
       of Uthotrity alone,     .     . iH. 677
       of   Uthotomy by the  recto-
         vesical method,     .     . Hi. 615
       of ovariotomy,   .     .     . UL 922
       of paracentesis of the chest.. iii. 858
       puncture of the bladder,    . Ui. 839
       recto-vesical Uthotomy,     . iii. 615
       reduction of hernia, by taxis, Ui. 904
       of strabismus,    .     .     .   i. 541
       of tracheotomy,  .     .     . iu. 842
       trephining  Hi  fractures   of
         cranium, .     .     .     .  ii. 512
       wounds of head,  .     .     .  U. 532
       un-united fractures treated by
         the  seton,     .     .     .  H. 316
Stercoral fistulas, anaplasty  of)     . •  i 619
SteUated bandages,     .     .     .   i. 179
Stenon's duct, fistulas of,     .     . Ui.  27
Sterno mastoid, section of)  for wry
         neck,    .     .     .     .   i. 466
Sternal end of clavicle, its exsection,  u. 476
Sternum bandages for fracture of)  .   i. 187
       exostosis of)     .     .     .  ii. 718
       exsections of)                ii. 390
       trephining of,                ii. 538
Stiffness and  false anchylosis of the
         lower jaw,     .     ,     . HL 819
Stomach, fistulas of,                iU 214
       foreign bodies in,      .     .  ii. 741
       lead bar removed from,     . Hi. 864
Stone crushing—see Lithotrity,     Ui. 660
Stone Hi the bladder,    .     .     .Hi. 560
           see Lithotomy. 
986                                  INDEX.
Stones, peas, cherry-pits,  Ac., in  the
           nose,   .    .    .    . Hi.  72
Strabismus, operation for,    i. 511, Hi. 938
       accidents from the operation,  L 522
       counter  indications  to  the
         operation,     .    .    .  i. 531
       varieties of)  .    .    .    .  i. 531
Strangulated hernia,    .    . Ui. 233, 341
       femoral hernia,   .    .    . iu. 358
       inguinal.....Hi. 341
       umbilical.....Hi. 368
       ventral and  others,    .    . HL 375
       statistics of hernia,    .    .     ib.
Stangulation Hi hernia, where seated, iii. 235
       signs of,     .    .     .    . HL 236
       of tumors, &c, by Ugature Hi
         mass,     .    .     .    . H. 730
       internai    .    .     .     .Hi. 279
       of invaginated  intestine, in
         cases of artificial anus,  .  iu. 298
       of the penis,     .     .     . iu. 443
Straw splints,     .    .     .     .   L 129
Straps adhesive in  ulcers and  ab-
         scesses of the groin,      . iL 592
         adhesive in dressing,     .  i. 206
       adhesive in  the  treatment of
         fractures of the leg,  .     .  iii. 898
Stricture of the cesophagus,   .    . iii. 161
       hi strangulated hernia,     .  HL 235
       division of the,   .     .     .  iii. 263
       of the rectum,   .     .     .  iii. 765
       of the urethra,   .     . Hi. 714, 939
       cauterization in,  .     .     .  Hi. 731
       catheterism,  forced and  dUat-
         ing,.....iii. 717
       dilation of urethra,     .     .  iii. 724
       forced injections  in,   .     . Hi. 719
       incisions  and   scarifications
         in......HL 722
       perinaeal section,     .    . Hi. 939
       topical applications to, .     . iii. 739
Strings and tapes.....L 134
Strumous diathesis,     .     .    . iL 689
Stumps of amputated limbs, changes
         in,.....ii 130
       conical,    .... ii. 123
       exsection  of,    .     .    . iL 126
       position of,  .    .     .    • ii. 114
Styptics and  refrigerants hi lesions
         of arteries,    .    .    .  L 676
Subclavian aneurism, case of,     .  i. 909
       first case  of ligature of inno-
         minata for,    .    .    .  i. 912
       artery,  operations on,   i 831, 896,
                    909, 951, 956, 962, 966
         compression of,     .     .  i 685
         statistics of ligature of the,
           without the scaleni mus-
           cles,    .    .     .     .  i 842
         statistics   of  its  ligature
           within  the scaleni,   .    i 834
         first case  of ligature of the
            left, within the scaleni,   i 835
         distal method  of ligating the, i. 841
         distal operation on the, for
            aneurisms  of the innom-
            inata,  .    .     .     .  i 876
i. 692
i. 381
UL 900
H. 666
ii. 622
iii. 128
iii. 127
    ib.
iii.  33
H. 598
 L 110

iii. 153
 i  71
 Subclavian, wound of the,
 Subcutaneous bridles, division of,  .
       perforation of un-united frac
         tures,    ....
       puncture of synovial cysts,  .
       fatty tumors,
 Subhyoid region, tumors of,
 SubmaxUlary gland,    .
         extirpation of,  .
         fistulas of,
       lymphatic tumors,
 Substitutes for lint,
 Suffocative symptoms, reUeved  by
       olive oil,
 Sulphate of iron, in erysipelas,     .
 Sulphuric  ether, as an anaesthetic, in
         surgical operations,  .     . Ui. 822
           see also Chloroform.
 Supernumerary limbs, removal of) •  ii  82
 Supplemental Appendix, vol. i, p. xliU.
 Supplementary articulations, made in
         cases of anchylosis,  .     .   i 489
 Suppression  of  drains,  as  issues,
         setons, &c, &c,     .     .   i. 293
 Suppuration,  excessive,  amputation
         in cases of)     .     .     .  H.  79
 Supra clavicular tumors,      . ii 604—625
 Supra pubic, or high operation  of
         lithotomy,      .     .     . Hi. 620
         puncture of the bladder,. Hi. 223,
                                       749
 Surgery,  conservative, Hi  avoiding
         amputations,   .     .     .  ii 271
       its definition and division,   .   i.   1
       minor, .     .     .     .     .   i  88
 Surgical beds,      .     .     .     .   i 134
       operations,   chloroform   and
         ether in, .     .     .     .Hi 825
 Suspensory bandages,   .     .  i 173—176
         for  females,    .     .     .   i 170
 Sutures, their use in uniting wounds,  i  57
       various kinds, as the inter-
         rupted quUled, glovers, Ac,  i 349
                                    —358
       see also the " clamp," Hi  ve-
         sico-vaginal fistulas,.     . iii. 874
       of the external ear,    .     . iii. 100
       in the radical cure of hernia, HL 223
       of  the  palate—see  Staphy-
         loraphy,   .     .    .     . Hi.  60
       of the perinaeum, .     .     . Hi. 538
       of the tendons,   .     .     . HL 942
       in urinary fistulas,     .     . iii. 753
       in recto-vaginal fistulas,    . iii. 535
       of the vesico-vaginal fistulas, iiL  521,
                                       874
       of  the cranium, separated Hi
         fractures.....iL 536
 Symblepharon,    .     .     .     .   H. 830
 Syncope from loss of blood,   .     .   i. 248
 Synovial cysts,    .     .     .     .   iL 662
       treatment of,                  ii. 663
       hematic cysts,    .    .     .   ii. 651
 Sympathetic nerve,  neuromas of,  .   ii. 618
 Symphysis pubis,  puncture  of  the
|         bladder, through it, .     .  Hi. 839
i Symphysiotomy,   ....  Hi. 545 
INDEX.
987
bystem, lymphatic,     .     .     .  ii.  37
       nervous,    .     .     .     .  ii.  38
       venous,     .     .     .     .  H.   1
Systematized operations and the  re-
         verse,    .     .     .     .   i.   4
Surgeon, his position while operating, L  18
Suspensory bandages,   .     .     .   i. 173
       to retain  catheter  Hi   the
         urethra,  .     .     .     .   L 171
       bandage for females,  .     .   i. 170
T bandages,.....i. 148
Table of muscles of the human body,
         in French and English—
         Appendix, vol. L, p. xix.
       statistical, of various  opera-
         tions—see Statistics.
TaU bandages,     .     .    .    .   i. 146
Talipes, or club foot,   .    .    .   L 449
Talus,  or forward club foot,  .    .      ib.
Tampons in alveolar hemorrhage,  .   L 693
       Hi hemorrhage  from the  nos-
         tril, .....iii.  74
Tapes in dressing, .     .    .    .   i. 134
Tapping, abdominai    ;    .    .  Hi. 205
       thoracic,   .     .    .    .  UL 157
Tarsal extremity of the fibula, its
         exsection,      .    .    .  «ii. 487
Tarsus, amputation of,   .     i. 588, u. 207
       division of tendons of, .    .   i. 416
       excision of,  .     .     .  U. 423, 481
       trephining of,     .    .    .  ii. 542
Tattooing in erectUe tumors, .    .  ii. 560
Taxis in hernia,   .     .    .    .  iH. 239
       compulsory and dangerous, .  iii. 241
       position in making,   .    .  HL 245
       remaining of the strangulation,
         after apparent reduction by, iii. 282
Tearing out of the nasal polypi,    .  HL  79
Temporal bone, fracture of its petrous
         portion,   .     .    .    .  H. 526
Temporal artery,  bleeding Hi, .    .   L 265
         aneurism of)    .     .    .   i. 846
         compression of,     .    .   i. 681
Teeth operations on,    .    .  i. 313—326
       transplanting of teeth, .    .   i. 560
Tenaculum,.....i.  45
Tendo Achilles, its  division in cases
         of club foot,    .     .  L 418, 485
         accidental  division or  rup-
           ture of).     .    .    .   i 418
         tenotomy  of,    .     .    .   i. 445
Tendons, accidental division of)    .   i. 399
       treatment of)     .     .    .   i. 401
       deformities  from  alterations
         of the,    .     .     .    .   i 399
       particular, how changed,    .   i 407
       pathology of the,  .     .  i 400, 434
       puncture of,  in  venesection,    i. 249
       treatment,  .     .     .    .   i 402
       suture of,   .     .    .    .  iii 942
Tenotomy  and nyotomy,     i.  501,  iii. 942
       see  also Appendix, vol. L, p. liii.
       in America, .     .     i.  501,  iii. 941
       or  division of the tendons of
         the axilla,      .    .    .   i. 442
                                     PAG*
Tenotomy of the arm,    .     .     .  i 440
         of the elbow,   .     .     .     ib.
         of the head,   .     .     .  i. 464
         of the foot,     .     .     .  i. 443
         of the leg,     .     .     .  L 462
         platyma myoides,   .     .  L 473
         sterno mastoid,     .     .  L 466
         tendo Achilles,     .     .  i. 445
         operations of club foot,   .  i. 448
         tendons of toes and of great
           toe,    .     .     .     .  i 452
         trapezius,      .     .     . HL 385
Tents in hydrocele,      .     .     .     ib.
Tenoraphy, or suture of tendons,   .  i. 405,
                                  Ui. 942
           Appendix L, p. HU
Testicle, diseases of,     .     .     . iu. 375
       condition of, in hydrocele,  . Hi. 379
       incisions  into  tunica,  albu-
         ginea of, in  cases  of  in-
         flamed.....HL 432
       puncture of) in hydrocele,   . HL 396
       removal of the, or castration, iii. 321
       situation of, in the  foetus,   . Hi. 427
Tetanus, amputation in, .     .     .  ii. 80
       exsection of nerves in, .     .  iL 41
       tracheotomy in,  .     .     . Ui. 845
Thigh, amputation of the,    L 950, ii. 246
       bandage for fractures of the,  i. 189
       anchylosis of the,     .     .  L 488
       bone, exsection of,  ii. 296, 305, 434,
                                     594
       bone, exsection of  head  of,   ii 504
       compression of the arteries of
         the,      .     .     .     .  i. 687
       exostosis of the, .     .     .  U. 723
       fatty tumors of the,   .     .  iL 627
       fracture of the,   .     .     . iii. 893
       nerves  of the,    .     .     .  ii. 53
       bone, bandages for fracture
         of the neck of) .     .     .  i. 88
       neuromas of the, .     .     .  U 613
       tendons  of,  their  accidental
         division or rupture,  .     .  L 426
       bone, trephining  of  the,  in
         cases of necrosis,   .     .  H. 545
       subcutaneous bridles and cica-
         trices of the,   .     .     .  i. 394
       supplementary or new articu-
         lation of the, made in a case
of anchylosis, .	. i. 491
Thorax,.....	. iii. 171
anaplasty of the, .	. i. 617
bandages for the, . . i.	165, 195
effusions into the,	. iii. 179
foreign bodies in,	. ii. 736
paracentesis of, . . iii.	187, 858
Thoracic, or upper extremities, par-	
tial exsection of,	. ii. 400
neuromas of,	. ii. 618
removal of tumors of, .	. iii. 178
Thread ribbon bandages,	. i. 120
or ligatures in aneurism,	. i. 712
Thrombus, ....	. i. 248
Thimble extracted from the nose,	. iii. 74
Thumb, amputation of, .	. ii. 150
excisions of the joints of,	. H. 449
 
988
INDEX.
 Thumb—continued.
        excision of first phalanx,    .  iL 443
        tenotomy of,     ...  i. 408
 Thyroid arteries, ligature of)  i. 848, Hi. 131
        cartilage, synovial cysts of)  .  U 651
        gland, hematic cysts of)     . Hi. 943
          injections into, .     .     . iiL 131
          extirpation of,  .     .     . iii. 132
          operations on,  .     . Hi. 128, 943
 Thyroidean laryngotomy,     .     . iii. 149
 Thyro-hyoidean laryngotomy,      . Hi. 150
 Thyroid, or obturator  hernia,  .     . iii. 372
       tumors, or those  adjacent to
          the thyroid gland,   .     . HL 135
 Tibia, bandages for fracture of,     .  i 188
       exostosis of the,  .     .     . ii. 722
       exsection of the,  .    .  iL 292, 426
 Tibial arteries,     .     .    .   L 760, 907
       nerves,      .     .     .     . ii.  52
 TibiaHs anticus  and posticus,  di-
         vision of their tendons, in
         club foot,                .  L 451
 Tibio  tarsal  articulation, its  exsec-
         tion,     .     .    .    . iL 456
 Tied tongue, operation for,   .    . HL  40
 Toes, amputation of,     .    .    . iL 193
       angulated, curved, and crook-
         ed, amputation of)  .     . ii.  85
       exostosis of the, .    .    .  i. 375
       section of their  ligaments,   .  i. 476
       subcutaneous bridles of)     .  i. 393
       sub-ungual fungosities of,   .  i. 375
       tenotomy of the, .    .     . L 443
Toe-naiL  inverted  or  imbedded  in
         the flesh, .    .    .    .  L 363
Tongue, adhesion of the,      .     . HL  42
       cancer of)   .     .    .     . Hi.  44
       depression of,               iii.  53
       diseases of, .    .    .    . iii.  48
       hypertrophy of,   .    .  Hi. 48, 944
       removal of) .    .    .     . Hi.  44
       retraction  of the, Hi removal
         of the lower jaw,    .     .  iL 332
       tied, operation for,    .     . Hi.  40
       reversion of the, .     .     .Hi.  40
       tumora of the,    .    .     . UL  40
         see also Appendix, vol. i., p. lxi.
Tonsils,......iH. 946
       abscesses of the, .    .     . HL  56
       cancer of)   .    .    .     .Hi.  59
       enlargement of,   .    .     . UL  49
       hemorrhage  after  removal of
         the,.....Hi. 946
       removal of the,  .    .   HL 54, 945
TonsiUitome,.....HL 945
Topical applications, in hemorrhage, i.  42
Torsion of  arteries,    .    .    L 48, 708
       of nasal polypi  .     .     . Hi  82
TorticoUis, or wry neck—see  Teno-
         tomy,    .               .  i 464
Tourniquet, .    .    .      .     . i  21
Trachea  and larynx, foreign bodies
         in,.....Hi 138
       partial excision  ol)    .     .  ii 389
Tracheotomy,.     .     . Hi. 144—157, 846
       Hi cases of croup,  for removal
         of foreign bodies,  &c,    . HL 150
 Tracheotomy—continued.
        to  relieve dyspnoea,  in cases
          of goitre,      .     •     • »••  155
        in puerperal convulsions,    . iiL  841
        in tetanus,  .     •     •     -iii  844
        statistical table  of cases  re-
          quiring tracheotomy,     . Hi.  841
 Tracheotome, or instrument for per-
          forming tracheotomy,     . iii.  847
 Trancurrent cauterization,    .     .  U.  690
            see Caustics.
 Transfusion in hemorrhages,  .     . iii  948
 Transplantation of parts,    i 560, 599,  609
            see Anaplasty.
 Traumatic hemorrhages, .     .     .  i  671
        their treatment,  .     .     .  i.  677
 Trapezius muscle, its division.      .  i.  473
 Tremulous iris,     .     .     .     .  ii.  845
 Trephining,.....H.  609
        of the cranium,   ...     ib.
        of the facial bones,    .     .     ib.
        of the lower jaw,      .     .  ii  45
        of the lower extremities,    .  H.  542
        of the ribs, .     .    .     .  H.  540
        of the sternum,   .     .     .  H.  538
       of the spine,      .    .     .  ii.  541
       of the upper extremities,    .  U.  546
       Hi abscesses of bones,  .     .  ii  544
       in infancy,  .     .     .     .  ii.  525
       operation of)      .  '  .     .  H.  516
       instruments,      .    .     .  ii  614
       new instrument for,   .     .  H.  515
 Triangular bandages,    .    .     .  L  149
 Triceps cubiti tendon, its division or
         rupture,  .     .    .     .  L 414
       tenotomy of)      .    .     .  L 440
 Trichiasis,   .    .     .    ,     . ii. 821
 Trocar,......i. 348
 Trochanter major, its exsection,     . H. 435
 Trough boxes, or gutters,    .     .  L 133
 Trunks, nervous,  their excision,     . H.  55
 Trusses,......l 200
           see Hernia.
       for inguinal hernia,    .     . HL 339
 Tubercle carotid—see Vertebral  ar-
 m  .     . tery>     •     •    •    .  i. 852
 luberosity of the eschium, its partial
         exsection,     .    .     . ii. 398
 lube, eustachian, catheterism of,   . Hi. 110
Tubular aneurisms of  the   femoral
         artery, case of,      .     .  i. 705
Tumors"......H.548
       aneunsmai .     .    .     .  L 665
bony,
cysts,  .
cartilaginous,
cancerous,  .
elephantine,
erectile,
exostosis,
fatty, or wens,
fibrous,
                          .  U. 714
                          .  H. 639
                          .  ii. 670
                          .  iL 694
                          .  U. 631
                 . L 912, 950, ii. 552
                          .  ii. 714
                          .  ii. 619
                     .  H. 691, 755
fungous and vascular,
»UUgUua ana vascular, .  ii. 552 755
fungous,  Ugature  of carotid  '
  for its safe removal, .    .  L 931
hematic,    ...       u g33
hemorrhoidal,    \    \    ' HL 771 
INDEX.
989
  Tumors—continued.
         J?orny,.....H  551
         hpomatous, .    .     .     .  u. 619
         lymphatic,  .    .     .     .  u. 584
         neuromatic,      .     .     .  H. 607
         in the orbit,      .      i. 534, ii. 834
         osseous,    .    .     .     .  U. 670
         pseudo cancerous,     .     .  H. 710
         removal of, by ligature,     .  H. 726
         sanguineous,    .   H. 552, 683, 755
         sebaceous,  .    .     .     .  iL 639
         serous cysts,     .     .   H. 659, 670
         synovial cysts,   .     .     .  H. 659
         vascular, or erectOe,   .   H. 552, 755
         of particular parts or regions.
         of abdominal walls,    .     . HL 213
         of lower abdominal cavity,  . iii. 208
         of antrum.....iiL  99
         of breast,   .... iii. 170
         of clavicle (osteosarcoma, Ac.) ii. 409
         cUtoris,     .... iii. 452
         of cranium, .    .     .     .  H. 755
         of external ear,  .     .     . Hi. 100
         of eye,      .    .     .     .  H. 905
         see Eye,    .    .     .     .  H. 837
         of eyeUds,   .    .     .     .  ii. 827
         of genital female organs, iii. 450—508
         of genital male organs,  Ui. 411   450
         of the head,      .     .     .  ii. 755
         of hemorrhoidal,  .     .     . iii. 771
         hernial,    .     .     .     . iH. 215
         of humerus,      .     .   U. 407, 673
         of integuments,  .     .     .  ii. 549
         oflips,     .     .     .     . HL   19
         of liver,     .     .     .     .Hi. 207
         of nose,    .     .     .   H. 383,  777
         of mammary gland,    .     . Hi. 170
        of nymphae,      .     .     . iii. 453
        of mouth,  .     .     .     . Ui.  39
        of orbit,    .     .     i.  534, ii.  834
        of ovary,   .     . iii 208—213,  932
        of palate,   .... iii.   49
        of parotid gland,  .     .     . iH.  115
        of salivary regions,     .     . iii.  114
        of scapula,  .     .     .     . H.  418
        of submaxiUary gland,      . Hi.  127
        of scrotum,  .... iii. 433
        of thorax,  .     .    .    .Hi.  179
        of tongue,  .     .    .    . Hi.  40
        oftonsUs,   .     .    .    . Hi.  49
        of thyroid gland, .    .    . Ui. 128
        adjacent    to  the   thyroid
          gland,    .     .    .    .Hi. 135
        in  the  vicinity  of  larnyx
          and trachea,   .     .    . Hi. 138
        of the vulva,     .     .    . Hi. 450
       treatment of,     .     .    .  u. 688
          see Appendix, vol i., p. lx.
Tunica  albuginea  testis,  incisions
          into,      .     .     .     .Hi. 432
Tunica vaginaUs, hernia of,   .     . Hi. 327
Twisted  rope, Hi  reducing disloca-
         tions.....Hi. 854
Tying of arteries,   .     .     .     .  L-712
           see Arteries.
Tympanum, perforation of the mem-
         brana tympani,      . Hi. 108, 946
                    U
Ulcers, amputation for,  .
Ulna, excision of,  .
      entire removal of,
Ulnar artery, aneurism of)
         ligature of,
      nerve, excision of,
         neuromas of,  .
UmbUical hernia,  .
      operations for,
      viscera in,  .
Umbilicus, fistulas of,
                                     PAGS

                                  .  iL 614
                             .    403—406
                                  .  H. 460
                                  .  i. 900
                             .  i. 811—815
                                  .  H.  49
                            U. 79—86, 616
                                  . iii. 365
                                  . HL 368
                                  . HL 367
                             .m    . Hi. 751
 Union of wounds, by the first inten-
         tion, .....i.  54
         by the second, .         L 60, 230
 Upper jaw, exsection of)      .     .  ii. 375
            see Appendix, vol. L, p. L
       see also maxUlary sinus,     . iU.  93
 Uniting bandages, .     .     .     .  i. 151
 Un-united fractures, acupuncture in,  H. 304
         caustics in the treatment of, ii. 303
         compression in cases of)     H. 301
         exsection Hi cases of,  ii. 294, 298
         cases of exsection of,     .  H. 304
         frictions in cases of)  .     .  ii. 300
         immovable dressings in,   . u. 301
         ivory pegs Hi the treatment
            of,      .     .     .     .  iL 309
         new method of treating by
            subcutaneous    perfora-
            tions,  .... iii. 900
         rasping, in treatment of)  . ii. 303
         setons, in treatment of,    . H. 302
         cases treated by the seton, ii. 315
         treatment of)  .    H. 309, HL 900
         statistical table of cases of,
            and how treated, .    . ii. 316
             see Statistics.
 Upper extremities, amputation of,   H. 136
         artificial articulations in,  .  i. 490
         exsection of,   .    .    . H. 490
            see Exsections.
         trephining of bones of,    .  H. 546
 Upper jaw,  exsection of,     .     . H. 375
           see Appendix, vol. L,  p. L
      see also MaxUlary Sinus,    . iii. 93
Ureter, fistulas of) .     .     .     . HL 751
Ureterotomy,  or incision  into  the
         ureter,   .     .     .     . Hi. 693
Urethrotomy,  or  incision into  the
      urethra,     .     .     .     . HL 648
Urethra,  female, contraction of mea-
      .  tus of,    ...      Hi. 731
      female, excision of)    .     .Hi. 558
      bandage for fixing a catheter
         in the,    .     .     .     .  j. 17^
      male, calcuU in,   .     .     . Hi. qqi
         catheterism of).     .     . Hi. 704.
         cauterization of,     .     . Hi. 73^
            see Appendix, vol. L, p. lxii.
         contraction of meatus of,  . Hi. 730
         dilatation of,   .    . HL 724J 940
         fistulas of)                jij' 751
        forced injections into,    . Hi. 718
        foreign bodies in,   .    . ft. 755
        incisions and scarifications
          of>     •    •-. Hi. 719 
990
INDEX.
 Urethra—continued.
          injections of,   .     .     .   L 222
            forced, .     .     .     . HL 718
          organic   contractions,   or
            strictures of)      .     . iii. 740
          polypi of)      ... iii. 741
          strictures of)   .  iii. 714, 740, 939
 Urethral calculi, in the tissues of the
          vaginal septum,     .     . Hi. 693
       fistulas,     .     .     .     . HL 751
 Urinary apparatus,  diseases  of)  and
          operations upon,     .     . iii. 560
       calculi,     .     .     . HL 560, 702
          chemical action on,  .     . Hi. 700
          external to the bladder,  . iii. 691
       diseases,   .... iii. 560
       fistulas,    .... iii. 750
         recto-vaginal,  .    H. 534, iii. 867
          recto-vesical,   .     .     . iiL 750
         vesico-vaginal,     . iii. 521, 874
       passages, foreign bodies in,   U. 741
Uthroplasty,  or  anaplasty of  the
         urethra,             .   i. 622, 644
Useless Umbs, amputation of,       . ii. 85
Uterine, sound,    .      .    .     . iu. 948
Utero-gestation, its  effect on  un-
         united fractures,    .    . ii.  299
Uterotomy, vaginal,      .    .    . iH. 554
Utero-vesical fistulas,   .    .    . iii. 872
Utero-vesico vaginal,   .    .  Hi. 521, 872
Uterus, cancer of,  .     .    .    . iii. 558
       cancer of neck of,     .    . iU 498
       Caesarean operation,   Hi. 545—548
       diseases of  the,   .    .    . iii. 462
       excision of the,   .    . iii. 502, 558
       foreign bodies in the, .    . iii. 478
       inversion of)                 Hi. 510
       occlusion of neck of the,    . iii. 462
       pessaries uterine,     .    . iii. 471
       polypi of the,     .    .    . Hi. 478
       prolapsus of the,   Hi.  465, 504, 508
       puncture of the, ..    .    . iik 462
       reduction of the,  .    .    . iii. 470
       removal of the,  by Ugature, . iii. 557
       a case in which it was torn out, iii. 558
       retroversion of the,    .     . iii. 464
       rupture of the,   .    .    . iii. 555
       speculum uterine,    .  HL 502, 558
       utero-vesical fistulas, .  Hi. 521, 872
       utero  vesico  vaginal,  and
         vesico-vaginal  fistulas,  Hi. 873—
                                      887
       new  American mode of treat-
         ment of these fistulas, iu. 873—887
Uvula, cauterization of)      .    . iii.  58
       excision of) .     .    .    . Hi.  57
Vaccination, .	. 305, 309
anomaUes of)	. i. 308
operation of)	. i. 305
progress of) .	. i. 307
of erectile tumors,	. iL 555
       preservation and transmission
         of the virus,   .     .     •   i 309
Valsalva's  method of curing aneu-
         risms.....i 674
 Vaginal, anaplasty,     .     •    •   i- 624
       calculi,     •         •    •  iii. 693
       hernia,     .     •     •    •  *"■ 373
       hysterotomy,  or  incision  of
         the os and cervix  uteri,  . Ui. 554,
                                       912
       injections,  ....   i 224
       pessaries,   ....  iii 471
       septum, calculi in,     .    .Hi. 694
       speculum,   .     .     . iii. 502, 559
       uterotomy,  .     .     .  iii. 554, 912
 Vagina,  eversion  of mucous mem-
         brane of,  .     .     .    .Hi. 465
       excision of integuments,    .  Ui. 465
         of flap of,      ...  iii. 465
       foreign bodies in the,  .    .  Hi. 476
       imperforate,     .     .  HL 462, 950
       case of)     ...           ib.
            see Appendix, vol. L, p. lx.
       obliteration of the, Hi the treat-
         ment of vesico-vaginal fistu-
         las,  .....iii. 534
       occlusion of,     ...  iu. 458
       cases of occlusion,      HL  949—954
       from traumatic lesion, .     .  Hi. 461
       reversion, or eversion of the,  iii. 465
       tumors of the,    .     i. 624,  Hi. 454
       plasty—see Anaplasty,     .   i. 669
 Vagino rectal fistulas,   .     .    .Hi. 534
       vesical fistulas,   .     . Hi. 521, 872
 Vaginalis tunica, hernia of)   .    .  HL 328
 Varices,......ii.   2
       operations on,    .     .    .  U.  10
       particular,   ....      ib.
       remarkable  cases of,   .     .  ii.  12
       remarks  on—see Appendix,
         vol. L, lvH.
Varicocele,    .     .     .     .   H. 21—34
       complicated with hydrocele, HL 402
Varicose veins,     .     .     .   ii. 10—24
         pathological  diagnosis ob-
           tained from,  .     .     .  H.  34
         of the pudenda,     .     .  ii.  21
Varix, aneurismal,       .     .   L  698, 825
Varus,......i.450
           see TaUpes, or club foot.
Vascular tumors,   .     .     .     .  H. 553
           see Tumors.
Venesection......i. 236
Veins, bleeding from,    .     .     .  L 236
       compression of to arrest he-
         morrhage,      .     .     .  i. 836
       entrance of air into the,     .  L   80
       hemorrhage  from, in amputa-
         tion9)     •     .     .     .  ii. 118
       ligature of,  .     .     .     .  ij ^q
       wounds of,  ..,"."  iL   34
       cephalic, bleeding from,     ".  L 254
       external iliac, obliterated,  .  ii!   n
       internal jugular, rupture of)    u!   34
       Hgature of internal jugular,  .  ii. 371
       opening  of  an  abscess  into
         the internal jugular,      .  h.   36
       saphena,  Ugature of,   .     .  H.   37
       subclavian,  ligature of,     .      ib.
 Vena cana, obUterated,       .     U. 11,  34 
INDEX.
991
Velum palati, anaplasty of)   .     .  i. 606
            see Staphyloraphy.
         fissures of,                jy  qq
         polypi of, .     .     .     ] iii*  88
 venesection,  ...            i 236
       Hi strangulated hernia,      '. iU 246
       wounds  of the  brachial  ar-
         tery in,   .     .     .     .  i. 899
 Venous system, wounds of,   .     .  H.    1
Ventral hernia,    .... Hi. 371
Vertebral artery, compression of,   '.  i. 682
         ligature of)     .     .     .  L 852
Vertebrae, exsection of,  .     .     .  iL 391
       exostosis of,      .     .     .  iL 718
       trephining of,     .     .     .  U. 541
Vessels  of a  limb,  how  changed
         after Hgature of the  main
         trunk,    .  .   .     .     . - i. 748
Vesication,.....L 279
Vesical calculi,     .     .     .     .Hi. 560
Vesico-vaginal and recto-vaginal ana-
         plasty,   .     .     .     .  L 661
Vesico-uterine fistulas,  .     .     .Hi. 872
Vesico-vaginal lithotomy,     .     . in. 643
       utero vaginal fistulas,  .     . Hi. 873
       vaginal fistulas,   .     L 624, Hi. 521
         see Appendix, vol. L,  lx.
       closing up  of the vulva  in
         cases of)  .     .     .     .Hi. 530
       a new and successful method
         of operating, in vesico-vag-
            inal fistulas,  .     . Ui. 874:—887
Vessels,  operations  on—see   Ar-
         teries  and Aneurisms and
         Veins.
       cirsoid aneurisms of,  .     .  ii. 573
Vienna paste—see Caustics,  .     .  i. 297
         its use in erectile tumors,   H. 559
Violent injuries, amputation in cases
         of,  .     .     .     .     .  iL  63
Viscera, in an inguinal hernia,     . iiL 330
       in umbilical hernia,   .     . Ui. 367
       in hernia generaUy,   .     . HL 215
Vigo plasters,      .     .     .     .  i. 127
Vulva, closing up of the,  Hi vesico-
         vaginal fistulas,    . Hi. 531—535
       contraction of the,     .     . iii. 468
       diseases of the,   .     .     . iii. 450
       elephantiasis of the,  .     . UL 454
       imperforate,      .     . UL 458—462
       tumors of the,    .     .     . iii. 450
Vulvar hernia,     .     .     .     . Hi. 373

                    W
WaUsof thevagma, adhesions of) in. 462, 950
         tumors of)      ... Hi. 454
Warts and corns,   .     .     .     .  i 359
Water in the head,      .     .     .  H. 765
Wax in the ear, hardened,   .     . HL 102
Wedge instrument for opening the
         jaws, in false anchylosis,  .iiL  21
Wens,......ii 619
Wet bandages,    .    .    .     .  L 122
Wet linen, in dressings,  .    .     .  L 112
Weeping sinews, or synovial cysts,   ii. 663
White swellings, amputation for,   . U.  79
Wire gauze,  in  the  treatment  of
fractures, .	. iU. 888
Womb, cancer of the neck of) .	. iii. 498
cancer of the,	. iii. 558
Caesarean section,.	. iii. 548
diseases of the, .	. iii. 462
extirpation of the, . Ui.	502, 558
foreign bodies in the, .	. iii. 478
inversion of the, . iii.	510—514
occlusion of the neck	of
the, ....	. iii. 462
pessaries uterine,	. Hi. 471
polypi of the,	. HL 478
prolapsus of the, . iii. 465,	504, 508
reduction of the, .	. iii. 470
removal of the, by ligature,	. HL 558
retroversion of the,	. HL 464
rupture of the,	. iii. 555
Women, catheterism in,	. HL 713
hydrocele in,	. Hi. 409
inguinal hernia Hi,	. iH. 330
lithotomy in, . . Hi.	641, 916
prolapsus of the urethra in,	Hi. 741
sexual organs of,	. iii. 450
Wood, pieces of, as foreign bodies,	. iL 745
Wool, as a dressing,	. i. 110
Woolen bandages, .	. i. 118
Wrist, amputation of, . . L 590, ii. 159	
exsection of,	. H. 447
       division of ligaments of,     .  i. 476
       hematic cysts of, .     .     .  ii. 653
Wounds, action of air on,     .     .  i. 229
       of arteries,  .     .     .     .  i. 670
       compression of arteries in cases
         of).....i. 690
       of the anterior and posterior
         tibial arteries,  .     .    758—762
       of the aorta,      .     .     .  i. 670
       of the carotid,    .     .     .  L 860
       of  the epigastric  artery, in
         operating for  strangulated
         hernia,    .     .     .     .Hi. 350
       of the fibular artery,   .     .  i. 765
       of the arteries of the foot,   .  L 758
       general treatment of,   .     .  i. 230
       gun-shot,    .     .     .     .  H.   73
         amputation for,     .     .  H.   75
       gun-shot,  of the axilla,  liga-
         ture of subclavian,  .     .  L 962
       exsection of  bones in  gun-
         shot,     .     .     .     .  H. 284
       gun-shot, of the  brain, recov-
         ery from.....U. 531
       gun-shot, of the head,  .  iL 532, 735
       of the heart,      .     .   L 671, 754
       of the intestines,  in hernia,  . iU. 295
       of  the intestines  Hi  litho-
        tomy,     .     .     .     . iU. 608
       of the intercostal artery,     . UL 190
       from railroad accidents,     .  U.   76
       of the scalp,      .     .     .  U. 535
       of the subclavial artery,     .  i. 692
       of the thorax     .     .     .  U 736
       remarkable cases of,   .     .  U. 736
       tenotomy, in cases of,  .     .  L 428
       union of, by first intention,  .  i   55 
992
INDEX.
                                    PAGE
Wounds—continued.
      treatment  of) at first dress-
         ing,     .    .    .     .   i. 230
      union by second intention,  .   L  64
      of veins,  .    ;    .    . ii.  1—34
Wrist, amputation of,   .     . L 590,  H. 159
Wrist,  division of the Ugaments for
         rigidity,  .     .    .    .  i. 476
       exsection of,     .    .    .  U. 447
       hematic cysts of)      .    .  ii. 653
Wry neck,  or torticollis—see Teno-
         tomy,                  .  i 464 
 
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